游离股薄肌肌瓣联合腓肠神经移植重建腕部电烧伤患者手屈指和感觉功能的效果

夏成德; 狄海萍; 邢培朋; 黄万新; 薛继东; 曹大勇; 郭海娜; 刘磊; 栗鹏程

doi:10.3760/cma.j.cn501225-20221203-00525

游离股薄肌肌瓣联合腓肠神经移植重建腕部电烧伤患者手屈指和感觉功能的效果

doi: 10.3760/cma.j.cn501225-20221203-00525

1.
郑州市第一人民医院烧伤科，郑州　　450004
2.
郑州市第一人民医院骨科，郑州　　　　450004
3.
北京积水潭医院手外科，北京　　100035

基金项目:

河南省医学科技攻关计划省部共建重点项目 SBGJ202002126

详细信息

通讯作者:
栗鹏程，Email：doclipc@aliyun.com

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出版历程
- 收稿日期: 2022-12-03

Effects of free gracilis muscle flap combined with sural nerve transfer for reconstruction of digital flexion and sensory function of hand in patient with wrist electric burn

1.
Department of Burns, the First People's Hospital of Zhengzhou, Zhengzhou 450004, China
2.
Department of Osteology, the First People's Hospital of Zhengzhou, Zhengzhou 450004, China
3.
Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing 100035, China

Funds:

The Provincial and Ministerial Key Projects of Henan Medical Science and Technology Research Program SBGJ202002126

More Information

Corresponding author: Li Pengcheng, Email: doclipc@aliyun.com

摘要

摘要: 目的探讨游离股薄肌肌瓣联合腓肠神经移植重建腕部严重电烧伤患者手屈指和感觉功能的效果。方法采用回顾性观察性研究方法。2017年1月—2020年12月，郑州市第一人民医院烧伤科与北京积水潭医院手外科分别收治4例符合入选标准的腕部高压电烧伤患者，其中男6例、女2例，年龄12~52岁，腕部高压电烧伤分型均为Ⅱ型，正中神经均缺损。Ⅰ期应用游离股前外侧肌皮瓣修复创面，于创面愈合3~6个月后Ⅱ期应用游离股薄肌肌瓣联合腓肠神经移植重建患手屈指和感觉功能。肌瓣、神经切取长度分别为32~38、28~36 cm。将肌瓣供区和神经供区均拉拢缝合。术后观察和记录股薄肌肌瓣和腓肠神经成活情况、前臂受区创面愈合时间、肌瓣供区和神经供区缝合口愈合时间，随访供受区恢复情况。术后2年，根据中华医学会手外科学会上肢部分功能评定试用标准中手部肌腱、神经修复评定标准，评价手功能重建后屈拇屈指的肌力和手指感觉功能。结果术后股薄肌肌瓣和腓肠神经全部成活。前臂受区创面愈合时间为术后10~14 d，肌瓣供区及神经供区缝合口愈合时间为术后12~15 d，供受区恢复良好。术后2年随访，屈拇屈指肌力评定：5级者4例、4级者3例、2级者1例；手指感觉功能评定：S3 ⁺级者4例、S3级者2例、S2级者2例。结论对腕部严重电烧伤致手功能障碍患者，应用游离股薄肌肌瓣联合腓肠神经移植重建患手屈指和感觉功能，是一种较佳修复方法，且不会对大腿肌瓣供区和小腿神经供区造成较大损伤。
- 烧伤，电 /
- 手损伤 /
- 股薄肌 /
- 外科皮瓣 /
- 显微外科手术 /
- 腕 /
- 功能重建
Abstract: Objective To explore the effects of free gracilis muscle flap combined with sural nerve transfer for reconstruction of digital flexion and sensory function of hand in patient with severe wrist electric burn. Methods A retrospective observational study was conducted. From January 2017 to December 2020, 4 patients with wrist high-voltage electric burn admitted to the Department of Burns of the First People's Hospital of Zhengzhou and 4 patients with wrist high-voltage electric burn admitted to the Department of Hand Surgery of Beijing Jishuitan Hospital met the inclusion criteria, including 6 males and 2 females, aged 12 to 52 years. They were all classified as type Ⅱ wrist high-voltage electric burns with median nerve defect. In the first stage, the wounds were repaired with free anterolateral thigh femoral myocutaneous flap. In the second stage, the free gracilis muscle flap combined with sural nerve transplantation was used to reconstruct the digital flexion and sensory function of the affected hand in 3 to 6 months after wound healing. The cut lengths of muscle flap and nerve were 32 to 38 and 28 to 36 cm, respectively. The muscle flap donor area and nerve donor area were both closed and sutured. The survival condition of gracilis muscle flap and sural nerve, the wound healing time of recipient area on forearm, the healing time of suture in muscle flap donor area and nerve donor area were observed and recorded after operation, and the recovery of donor and recipient areas was followed up. In 2 years after operation, the muscle strength of thumb and digital flexion and finger sensory function after the hand function reconstruction were evaluated with the evaluation criteria of the hand tendon and nerve repair in the trial standard for the evaluation of functions of upper limbs of Hand Surgery Society of Chinese Medical Association. Results All the gracilis muscle flap and sural nerve survived successfully after operation. The wound healing time of recipient area on forearm was 10 to 14 days after operation, and the healing time of suture in muscle flap donor area and nerve donor area was 12 to 15 days after operation. The donor and recipient areas recovered well. In the follow-up of 2 years after operation, the muscle strength of thumb and digital flexion was evaluated as follows: 4 cases of grade 5, 3 cases of grade 4, and 1 case of grade 2; the finger sensory function was evaluated as follows: 4 cases of grade S3 ⁺, 2 cases of grade S3, and 2 cases of grade S2. Conclusions For patients with hand dysfunction caused by severe wrist electric burn, free gracilis muscle flap combined with sural nerve transplantation can be used to reconstruct the digital flexion and sensory function of the affected hand. It is a good repair method, which does not cause great damage to thigh muscle flap donor area or calf nerve donor area.
- Burns, electric /
- Hand injuries /
- Gracilis muscle /
- Surgical flaps /
- Microsurgery /
- Wrist /
- Functional reconstruction
夏成徳、狄海萍、邢培朋、黄万新：手术设计和操作、论文撰写、病历资料整理及分析；薛继东、曹大勇、郭海娜、刘磊：患者管理、手术操作、资料收集；栗鹏程：手术设计和操作、论文修改

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参考文献(30)

[1]	文一臻,张丕红,任利成,等. 136例上肢电烧伤患者的临床特征及修复效果[J].中华烧伤杂志,2019,35(11): 784-789. DOI: 10.3760/cma.j.issn.1009-2587.2019.11.004.
[2]	沈余明,覃凤均,杜伟力,等. 濒临截肢四肢高压电烧伤患者的保肢策略[J].中华烧伤杂志,2019,35(11): 776-783. DOI: 10.3760/cma.j.issn.1009-2587.2019.11.003.
[3]	狄海萍,李永林,邢培朋,等. 皮瓣修复腕部高压电烧伤创面的手术时机选择[J].中华显微外科杂志,2019,42(2):166-169. DOI: 10.3760/cma.j.issn.1001-2036.2019.02.016.
[4]	尹凯,程琳,杜伟力,等. 169例腕部高压电烧伤住院患者流行病学调查[J].中华烧伤杂志,2020,36(6): 433-439. DOI: 10.3760/cma.j.cn501120-20200304-00119.
[5]	邢培朋,郭海娜,狄海萍,等.游离股前外侧皮瓣联合动脉血管重建修复腕部高压电烧伤创面的临床效果[J].中华烧伤杂志,2020,36(6): 419-425. DOI: 10.3760/cma.j.cn501120-20200219-00067.
[6]	沈余明,马春旭,覃凤均,等. 腕部高压电烧伤创面修复与功能重建[J].中华烧伤杂志,2017,33(12): 738-743. DOI: 10.3760/cma.j.issn.1009-2587.2017.12.004.
[7]	ShenZY, ChangZD, WangNZ. Electrical injury of wrist: classification and treatment-clinical analysis of 90 cases[J].Burns,1990,16(6):449-456. DOI: 10.1016/0305-4179(90)90076-9.
[8]	侯春林,顾玉东.皮瓣外科学[M].2版.上海:上海科学技术出版社, 2013: 553-556.
[9]	王增涛,王一兵,丁自海.显微外科临床解剖学图谱[M].济南:山东科学技术出版社,2009: 521-531.
[10]	潘生德,顾玉东,侍德,等.中华医学会手外科学会上肢部分功能评定试用标准[J].中华手外科杂志,2000,16(3):130-135. DOI: 10.3760/cma.j.issn.1005-054X.2000.03.003.
[11]	于建农,黄宗坚,吴煜,等.吻合血管肌腱移植重建屈指功能[J].中华显微外科杂志,2002,25(1):17-19. DOI: 10.3760/cma.j.issn.1001-2036.2002.01.007.
[12]	胡雷鸣,段虹昊. 同种异体肌腱移植修复手部肌腱缺损及指功能重建的疗效[J].实用骨科杂志,2020,26(1):23-26.
[13]	陈浩然,王古衡.同种异体肌腱在上肢损伤重建中的应用进展[J].中华创伤骨科杂志,2022,24(8):733-736. DOI: 10.3760/cma.j.cn115530-20220426-00231.
[14]	邢帮荣,史德海,庄泽. 同种异体肌腱联合股前外侧皮瓣一期修复手背软组织缺损[J].中华显微外科杂志,2013,36(1):24-27. DOI: 10.3760/cma.j.issn.1001-2036.2013.01.007.
[15]	顾斌,姜浩,李青峰.游离复合皮瓣一期修复腕晚期电烧伤畸形[J].中华整形外科杂志,2006,22(1):31-33. DOI: 10.3760/j.issn:1009-4598.2006.01.008.
[16]	HouY,QinBG,YangJT,et al.Restoration of finger and thumb movement using one-stage free muscle transplantation[J].J Plast Surg Hand Surg,2016,50(3):130-134.DOI: 10.3109/2000656X.2015.1120216.
[17]	陈山林,童德迪,王树锋,等. 游离股薄肌移植重建前臂屈指功能[J]. 骨科临床与研究杂志,2016,1(1):39-44. DOI: 10.3969/j.issn.2096-269X.2016.01.008.
[18]	薛云皓,王树锋, 陈山林,等. 游离股薄肌移植重建上肢部分功能24例报告[J]. 中国骨与关节杂志,2017,6(4):262-265. DOI: 10.3969/j.issn.2095-252X.2017.04.006.
[19]	周海波,张靖,姜磊,等. 游离股薄肌肌皮瓣联合膝上内侧皮瓣重建屈伸指功能疗效观察[J].浙江临床医学,2017,19(9):1684-1686.
[20]	陈超杰,任高宏. 游离股薄肌移植在创伤后肢体功能重建中的应用[J].中华创伤骨科杂志,2019,21(1):85-89. DOI: 10.3760/cma.j.issn.1671-7600.2019.01.016.
[21]	ArmangilM, ÜnsalSŞ, YıldırımT, et al. Outcome of free gracilis muscle transfer for the restoration of elbow flexion in traumatic brachial plexus palsy[J]. Jt Dis Relat Surg, 2021,32(3):633-641. DOI: 10.52312/jdrs.2021.225.
[22]	HinchcliffKM, KircherMF, BishopAT, et al. Factors impacting the success of free functioning gracilis muscle transfer for elbow flexion in brachial plexus reconstruction[J]. Plast Reconstr Surg,2022,149(5):921e-929e. DOI: 10.1097/PRS.0000000000009036.
[23]	魏在荣,陈伟. 皮瓣移植神经功能重建的研究进展[J]. 遵义医学院学报,2016,39(1):1-5.
[24]	时海军,刘敏,牛志勇. 应用显微外科技术修复上肢神经缺损的临床疗效[J].中华显微外科杂志,2009,32(3):254-255.DOI: 10.3760/cma.j.issn.1001-2036.2009.03.039.
[25]	梁虹宇,李养群,杨喆,等.股薄肌在软组织修复重建中的应用[J].中国美容整形外科杂志,2019,30(7):416-418,422. DOI: 10.3969/j.issn.1673-7040.2019.07.010.
[26]	王彦进,陈振雨,肖义青,等.股薄肌皮瓣修复会阴部缺损的临床应用[J].中国美容整形外科杂志,2012,23(9):539-541. DOI: 10.3969/j.issn.1673-7040.2012.09.009.
[27]	王克明. 股薄肌在整形外科中的应用[J]. 组织工程与重建外科杂志,2017,13(2):116-117. DOI: 10.3969/j.issn.1673-0364.2017.02.017.
[28]	VenkatramaniH,BhardwajP,SabapathySR.Role of free functioning muscle transfer in improving the functional outcomes following replantation of crush avulsion amputations of the forearm[J].Injury,2019,50 Suppl 5:S105-110.DOI: 10.1016/j.injury.2019.10.059.
[29]	StevanovicM, SharpeF. Functional free muscle transfer for upper extremity reconstruction[J]. Plast Reconstr Surg,2014,134(2):257e-274e. DOI: 10.1097/PRS.0000000000000405.
[30]	LinCH, ZhuZS, LinCH, et al. Primary free functioning muscle transfer for fingers with accompanying tendon transfer for thumb provide one-stage upper extremity composite reconstruction in acute open wound[J]. J Trauma Acute Care Surg, 2012,72(3):737-743. DOI: 10.1097/TA.0b013e31822a27b6.

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1 股薄肌临床解剖图

注：1为大隐静脉，2为大收肌，3为股薄肌，4为长收肌，5为股薄肌动、静脉，6为闭孔神经股薄肌支

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2 股前外侧肌皮瓣修复患者左腕部电烧伤创面及游离股薄肌肌瓣联合腓肠神经重建患手屈指和感觉功能的效果。2A.左腕部掌侧及手掌高压电烧伤后8 d，部分肌腱裸露坏死；2B.扩创后左手拇长屈肌腱、第2~5指屈指深和浅肌腱和旋前方肌等变性坏死，正中神经缺损；2C.切取后的股前外侧肌皮瓣；2D.术后皮瓣存活良好，手指无屈曲功能；2E.设计左股薄肌肌瓣；2F.切取后的游离股薄肌肌瓣；2G.自体腓肠神经切取后；2H.术中腓肠神经对折后吻合于正中神经缺损区；2I.股薄肌近端腱膜与屈肌肌群起点腱膜缝合后；2J.远端腱性组织与第2~5指屈指深肌腱编织缝合，肱桡肌肌腱与拇长屈肌腱断端缝合后；2K、2L.分别为术后2年左手指伸直位和屈曲情况，功能恢复良好

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