Clinical effects of early rehabilitation treatment after repair surgery of skin and soft tissue defects accompanied by extensor tendon injury on the back of hand
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摘要:
目的 探讨手背皮肤软组织缺损伴伸肌腱损伤修复术后早期康复治疗的临床效果。 方法 该研究为回顾性非随机对照研究。2015年2月—2023年2月，空军军医大学第一附属医院收治24例符合入选标准的手背皮肤软组织缺损伴伸肌腱损伤患者（男15例、女9例，年龄12~55岁），采用皮瓣移植结合肌腱移植或吻合的方法修复创面。根据术后康复治疗介入时间的不同，将患者分为常规康复组和早期康复组，每组12例。早期康复组患者于手术后即刻开始进行康复治疗，由专科康复医师根据患者术后不同时期的特点进行康复指导。常规康复组患者于术后第3周开始进行康复治疗，且其康复治疗内容与早期康复组患者术后第2周开始的康复治疗相同。2组患者均在院康复治疗至术后6周。观察术后6周内皮瓣血管危象及肌腱断裂发生情况。术后6周，采用徒手肌力测定法测量患手示指和拇指对捏力、侧捏力、三点捏力和握力；采用总主动活动度法评定患手手指关节活动度，并计算优良比；采用Carroll上肢功能评定法对患手功能进行评分和评级。 结果 术后6周内，仅常规康复组有1例患者发生静脉血管危象，经二次手术探查及血管吻合后皮瓣成活；2组患者均未发生肌腱断裂。术后6周，2组患者患手示指和拇指对捏力、侧捏力、三点捏力和握力比较，差异均无统计学意义（ P>0.05）；早期康复组患者患手手指关节活动度优良比为11/12，高于常规康复组的7/12，但差异无统计学意义（ P>0.05）；早期康复组患者患手功能评分为（90±6）分，明显高于常规康复组的（83±8）分（ t=2.41， P<0.05）；早期康复组患者患手功能评级明显优于常规康复组（ Z=2.04， P<0.05）。 结论 对手背皮肤软组织缺损伴伸肌腱损伤患者于修复术后早期行康复治疗，可改善患手功能，但不会增加手术相关并发症，值得临床推广及应用。 Abstract:Objective To explore the clinical effects of early rehabilitation treatment after repair surgery of skin and soft tissue defects accompanied by extensor tendon injury on the back of hand. Methods This study was a retrospective non-randomized controlled study. From February 2015 to February 2023, 24 patients (15 males and 9 females, aged 12-55 years) with skin and soft tissue defects accompanied by extensor tendon injury on the back of hand, who met the inclusion criteria and were repaired with flap transplantation and tendon grafting or tendon anastomosis, were admitted to the First Affiliated Hospital of Air Force Medical University. According to different intervention time for postoperative rehabilitation treatment of patients, the patients were divided into conventional rehabilitation group and early rehabilitation group, with 12 cases in each group. Patients in early rehabilitation group received rehabilitation treatment immediately after surgery under the rehabilitation guidance of specialized rehabilitation physicians based on the characteristics of different postoperative periods. Patients in conventional rehabilitation group began rehabilitation treatment from the third week after surgery, and their rehabilitation treatment was the same as that of patients in early rehabilitation group from the second week after surgery. The patients in 2 groups were treated in the hospital until the sixth week after surgery. The occurrence of flap vascular crisis and tendon rupture were observed within 6 weeks after surgery. After 6 weeks of surgery, the manual muscle test was used to measure the pinching force between the index finger and thumb, lateral pinching force, three-point pinching force, and grip force of the affected hand; the total action motion method was used to evaluate the finger joint range of motion of the affected hand, and the excellent and good ratio was calculated; the Carroll upper extremity function test was used to score and rate the function of the affected hand. Results Within 6 weeks after surgery, only 1 patient in conventional rehabilitation group suffered from venous crisis, and the flap survived after the second surgical exploration and anastomosis of blood vessels; there was no occurrence of tendon rupture in patients of 2 groups. After 6 weeks of surgery, there were no statistically significant differences in pinching force between the index finger and thumb, lateral pinching force, three-point pinching force, or grip force of the affected hand between the two groups of patients ( P>0.05); the excellent and good ratio of the finger joint range of motion of the affected hand of patients in early rehabilitation group was 11/12, which was higher than 7/12 in conventional rehabilitation group, but there was no statistically significant difference ( P>0.05); the affected hand function score of patients in early rehabilitation group was 90±6, which was significantly higher than 83±8 in conventional rehabilitation group ( t=2.41, P<0.05); the function rating of the affected hand of patients in early rehabilitation group was obviously better than that in conventional rehabilitation group ( Z=2.04, P<0.05). Conclusions Early rehabilitation treatment for patients with skin and soft tissue defects accompanied by extensor tendon injury on the back of hand after repair surgery can improve hand function, but it would not increase surgery related complications, which is worthy of clinical promotion and application. -
Key words:
- Hand injuries /
- Surgical flaps /
- Rehabilitation /
- Braces /
- Skin and soft tissue defect /
- Extensor tendon injury
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参考文献
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1 带伸肌腱的足背皮瓣移植修复例1患者右手背及前臂皮肤软组织缺损及术后早期开始康复治疗的效果。1A.清创后可见右手背及前臂皮肤软组织缺损伴伸肌腱损伤；1B.带伸肌腱的足背皮瓣游离移植术中；1C.术后第1周，在手功能位制动支具保护下，辅助患手进行手指屈伸运动；1D.术后第2周，佩戴手动力型支具，行主被动康复训练；1E.术后第3周，去除手动力型支具，行主动屈曲和抗阻伸展运动；1F.术后第5周，进行手指主动屈曲运动；1G.术后第6周，患手可写字，功能恢复良好；1H.术后1年随访，患手握拳功能恢复；1I.术后6年随访，患手外形及握拳功能恢复良好
2 股前外侧皮瓣联合人工肌腱移植修复例2患者右手背皮肤软组织缺损术后行常规康复治疗的效果。2A.术后14 d，康复治疗前，右手关节僵硬，患者握拳困难；2B.术后第3周，佩戴手动力型支具，行主被动康复训练；2C.术后第4周，行手指关节松动治疗；2D.术后第6周，患手可基本完成握拳动作；2E.术后3年随访，患手外形恢复良好；2F.术后3年随访，患手功能恢复良好，可完成握拳动作
表1 2组手背皮肤软组织缺损伴伸肌腱损伤患者临床资料比较
表1. Comparison of clinical data between two groups of patients with skin and soft tissue defects accompanied by extensor tendon injuries on the back of hand
组别 例数 性别（例） 年龄 （岁， 创面 面积（cm 2， 患手（例） 创面愈合时间（d， 皮瓣类型（例） 肌腱损伤数量（例） 肌腱修复方式（例） 肌腱移植数量（例） 男 女 左 右 股前外侧皮瓣 足背皮瓣 1根 2根 ≥3根 仅肌腱吻合 仅肌腱移植 肌腱吻合+肌腱移植 1根 2根 ≥3根 常规康复组 12 7 5 32±12 60±18 4 8 14.1±0.9 8 4 1 5 6 5 5 2 2 3 2 早期康复组 12 8 4 34±11 61±20 5 7 14.2±0.7 8 4 2 4 6 5 6 1 3 2 2 t值 — 0.17 0.20 — 0.25 — — — — P值 >0.999 0.870 0.843 >0.999 0.804 >0.999 >0.999 >0.999 >0.999 注：常规康复组患者在皮瓣移植和肌腱修复手术后第3周皮瓣成活后开始行常规康复治疗，早期康复组患者在皮瓣移植和肌腱修复手术后即刻开始进行康复治疗；“—”表示无此统计量值；创面面积为清创后手及前臂背侧创面面积 
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表2 2组手背皮肤软组织缺损伴伸肌腱损伤患者术后6周患手肌力比较（kg，
表2. Comparison of muscle strength of the affected hand between two groups of patients with skin and soft tissue defects and extensor tendon injury on the back of hand in 6 weeks post surgery
组别 例数 示指和拇指对捏力 侧捏力 三点捏力 握力 常规康复组 12 4.6±1.0 6.9±1.5 5.9±1.5 22±5 早期康复组 12 4.8±0.9 7.4±1.3 6.3±1.3 24±5 t值 0.67 0.81 0.74 1.07 P值 0.511 0.428 0.465 0.295 注：常规康复组患者在皮瓣移植和肌腱修复手术后第3周皮瓣成活后开始行常规康复治疗，早期康复组患者在皮瓣移植和肌腱修复手术后即刻开始进行康复治疗
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表3 2组手背皮肤软组织缺损伴伸肌腱损伤患者术后6周患手手指关节活动度评级情况（例）
表3. Rating of finger joint range of motion of the affected hand in two groups of patients with skin and soft tissue defects and extensor tendon injury on the back of hand in 6 weeks post surgery
组别 例数 优 良 中 差 常规康复组 12 2 5 4 1 早期康复组 12 6 5 1 0 注：常规康复组患者在皮瓣移植和肌腱修复手术后第3周皮瓣成活后开始行常规康复治疗,早期康复组患者在皮瓣移植和肌腱修复手术后即刻开始进行康复治疗
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表4 2组手背皮肤软组织缺损伴伸肌腱损伤患者术后6周患手功能评级（例）
表4. Function rating of the affected hand in two groups of patients with skin and soft tissue defects and extensor tendon injury on the back of hand in 6 weeks post surgery
组别 例数 Ⅰ级 Ⅱ级 Ⅲ级 Ⅳ级 Ⅴ级 Ⅵ级 常规康复组 12 0 0 3 6 3 0 早期康复组 12 0 0 1 3 7 1 注：常规康复组患者在皮瓣移植和肌腱修复手术后第3周皮瓣成活后开始行常规康复治疗，早期康复组患者在皮瓣移植和肌腱修复手术后即刻开始进行康复治疗
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