Effects of the first dorsal metatarsal artery terminal branch flaps in repairing skin and soft tissue defects of fingers
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摘要:
目的 探讨第1跖背动脉终末支皮瓣修复手指皮肤软组织缺损的效果。 方法 该研究为回顾性观察性研究。2021年10月—2022年12月,苏州瑞华骨科医院收治44例（共55指）符合入选标准的手指皮肤软组织缺损患者,其中男39例（48指）、女5例（7指）,年龄18~54岁。清创后单个创面面积为1.5 cm×1.0 cm~3.0 cm×2.0 cm。术前行彩色多普勒超声检查定位第1跖背动脉及其终末支,根据创面情况,设计第1跖背动脉终末支皮瓣,单块皮瓣切取面积为1.7 cm×1.2 cm~3.2 cm×2.2 cm。对皮瓣供区创面移植同侧小腿内侧全厚皮片。记录采用的皮瓣类型及术中测量的第1跖背动脉终末支口径,术后1周观察皮瓣成活情况,术后2周观察皮瓣供受区创面愈合情况。末次随访时,参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患指的功能恢复情况,采用英国医学研究会感觉功能评定标准评定皮瓣感觉功能,采用温哥华瘢痕量表（VSS）评定皮瓣供受区瘢痕情况,对供区趾体行Allen试验判断其血运情况。 结果 31例患者采用单块型皮瓣、 2例患者采用血流桥接型皮瓣修复单个手指创面,8例患者采用2个单块型皮瓣同时修复2个手指创面,3例患者采用一蒂两瓣型皮瓣同时修复2个手指创面。术中测得第1跖背动脉腓侧终末支口径为0.40~1.10 mm,第1跖背动脉胫侧终末支口径为0.70~0.75 mm。术后1周,所有皮瓣均成活。术后2周,皮瓣供受区创面均愈合良好。所有病例均获得随访,时间为6~18个月。末次随访时,48指功能恢复情况评定为优,7指功能恢复情况评定为良；8个皮瓣感觉功能评定为S2级,47个皮瓣感觉功能评定为S3级,皮瓣两点辨别觉距离为8~14 mm；皮瓣受区VSS评分为3~6分,皮瓣供区VSS评分为4~7分；供区趾体Allen试验结果均为阴性,血运正常。 结论 第1跖背动脉终末支皮瓣具有供区相对隐蔽、解剖层次浅、术中操作简便、皮瓣设计灵活等优点,皮瓣切取不破坏趾体主要供血动脉,在修复手指皮肤软组织缺损的同时能最大限度地保护足趾供区。术后手指外形较佳、质地良好、感觉及活动功能好。 Abstract:Objective To explore the effects of the first dorsal metatarsal artery terminal branch flaps in repairing skin and soft tissue defects of fingers. Methods The study was a retrospective observational study. From October 2021 to December 2022, 44 patients with skin and soft tissue defects in 55 fingers who met the inclusion criteria were admitted to Suzhou Ruihua Orthopedic Hospital. There were 39 males (48 fingers) and 5 females (7 fingers), aged 18 to 54 years. The single wound area after debridement ranged from 1.5 cm×1.0 cm to 3.0 cm×2.0 cm. The color Doppler ultrasonography was performed before operation to locate the first dorsal metatarsal artery and its terminal branches, and a first dorsal metatarsal artery terminal branch flap was designed according to the wound condition, with the area of harvested single flap ranged from 1.7 cm×1.2 cm to 3.2 cm×2.2 cm. The wounds in the flap donor areas were transplanted with full-thickness skin grafts from ipsilateral inner calf. The type of flap was recorded, and the diameter of the terminal branch of the first dorsal metatarsal artery was measured during operation. The survival of the flap was observed one week after operation. The wound healing in the flap donor and recipient areas was observed two weeks after operation. At the last follow-up, the functional recovery of the affected fingers was evaluated by the trial standards for evaluation of partial function of upper extremity by the Hand Surgery Society of Chinese Medical Association, the sensory function of the flap was evaluated using the sensory function evaluation standard of British Medical Research Council, the scar in the donor and recipient areas of the flap was evaluated using the Vancouver scar scale (VSS), and the Allen test was conducted in the toe of flap donor area to evaluate the blood flow. Results The monoblock type flaps in 31 patients and flow-through type flaps in 2 patients were used to repair wounds in single finger, 2 monoblock type flaps in 8 patients were used to repair wounds in 2 fingers at the same time, and the single-pedicle and two-flap type flaps in 3 patients were used to repair wounds in 2 fingers at the same time. The diameter of the fibular terminal branch of the first dorsal metatarsal artery ranged from 0.40 to 1.10 mm, and the diameter of the tibial terminal branch of the first dorsal metatarsal artery ranged from 0.70 to 0.75 mm. All the flaps survived at one week after operation, and all the wounds demonstrated optimal healing in the flap donor and recipient areas at two weeks after operation. All patients were followed up for 6 to 18 months. At the last follow-up, the functional recovery of 48 fingers was evaluated as excellent, and the functional recovery of 7 fingers was evaluated as good; the sensory function of 8 flaps was rated as S2, and the sensory function of 47 flaps was rated as S3, and the two-point discrimination distance of the flaps was 8-14 mm; the VSS scores in the flap recipient areas ranged from 3 to 6, and the VSS scores in the flap donor areas ranged from 4 to 7; the Allen test result of the toes in the donor areas were all negative with normal blood flow. Conclusions The first dorsal metatarsal artery terminal branch flaps have several advantages, including relatively hidden donor area, shallow anatomical level, simple intraoperative operation, and flexible flap design. The flap is incised without damaging the main artery of the toe, which can repair skin and soft tissue defects of the fingers and ensure the utmost protection of the toes in donor areas. The fingers exhibit improved appearance, texture, sensation, and function after operation. -
Key words:
- Microsurgery /
- Surgical flaps /
- Finger injuries /
- Toes /
- Wound repair
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参考文献
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图 1 第1跖背动脉终末支皮瓣设计和切取示意图。1A.皮瓣设计示意图；1B.皮瓣切取过程中可见的主要血管和神经
注：1为第1跖背动脉与趾底动脉系统的交通支,2为第1跖背动脉胫侧终末支,3为第1跖背动脉腓侧终末支,4为趾背神经,5为第1跖背动脉
图 3 采用单块型第1跖背动脉腓侧终末支皮瓣修复例1患者右中指末节皮肤软组织坏死创面的效果。3A.术中清创前见右中指末节部分皮肤软组织坏死；3B.术中在右足第2趾胫侧设计皮瓣；3C.术中分离第1跖背动脉腓侧终末支与趾背神经；3D.术中皮瓣切取完成,测得皮瓣血管蒂口径为0.80 mm；3E.术后即刻皮瓣血运良好,外形不臃肿；3F.术后11个月随访时,皮瓣存活良好,皮瓣受区无明显瘢痕增生；3G.术后11个月随访时,手指背侧外形不臃肿,无明显色素沉着；3H.术后11个月随访时,皮瓣供区创面愈合良好,无明显瘢痕增生
图 4 采用一蒂两瓣型第1跖背动脉终末支皮瓣修复例2患者右环指和小指创面的效果。4A.入院时右环指、小指近指间关节屈曲挛缩；4B.术中左足皮瓣的设计；4C.术中分离第1跖背动脉终末支与趾背神经；4D.术中瘢痕松解后右环指、小指遗留创面并伴有肌腱外露,以及皮瓣切取后；4E.皮瓣覆盖创面后即刻,皮瓣血运良好；4F.术后13 d皮瓣成活,外形稍臃肿,无色素沉着；4G.术后10个月随访时,皮瓣外形不臃肿,无色素沉着；4H.术后10个月随访时,皮瓣供区创面愈合良好,有轻度瘢痕增生
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