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摘要: 几个世纪以来,人们一直在不断探索如何重建残缺的拇、手指。在曾经出现过的数百种术式中,19世纪下半叶出现的足趾移植重建拇、手指的方法效果最好,但是因技术水平限制,当时只能做足趾带蒂移植再造拇、手指,患者在治疗期间长时间处于手足固定在一起的不适体位,并且没有修复神经,术后再造的拇、手指感觉差,因而没有广泛推广应用。直到1966年杨东岳用吻合血管的足趾游离移植再造拇指取得成功,足趾移植再造拇、手指的术式才逐渐成为拇、手指再造的主流方法。足趾移植再造的拇、手指外形及功能与正常拇、手指仍有很大差别,并且多个拇、手指缺损时移植多个足趾修复对足部造成的损伤较大,不宜用足趾同期实施3个以上拇、手指的再造。2007年王增涛提出了“拇、手指全形再造”的理念和系列新术式：用多种组织组合拼装的方式设计组装出新的手指,改变了传统的足趾移植再造拇、手指的方法,由用足趾代替拇、手指的方式转变为制造新的拇、手指使足趾得以保留且能再造出外形与功能近似正常的拇、手指。近年来,拇、手指全形再造的理念与系列新术式已经开始在国内外推广。该文着重介绍拇、手指全形再造发展情况。Abstract: For centuries, people have been searching for ways to reconstruct the mutilated thumb and fingers. Among the hundreds of operation methods that have appeared, the method of toe transplantation to reconstruct the thumb and fingers, which appeared in the second half of the 19th century, had the best effect. However, due to the limitation of technical level at that time, only the pedicled toe could be transplanted to reconstruct the thumb and fingers. During the treatment period, the patient was in an inappropriate position where the hand and foot were fixed together for a long time, and the nerve was not repaired, so the thumb and fingers reconstructed after surgery had poor feeling. Therefore, it has not been widely used. It was not until 1966 when Yang Dongyue succussed in reconstructing the thumb using a free toe transplant with blood vessel anastomosis that toe transplantation gradually became the mainstream method of thumb and finger reconstruction. The appearance and function of the thumb and finger reconstructed by toe transplantation are still very different from that of the normal thumb and finger. Moreover, when multiple thumbs and fingers are defective, the transplantation of multiple toes for repair will cause great damages to the foot, so it is not suitable to reconstruct more than three thumb and fingers using toes in the same period. In 2007, Wang Zengtao proposed the concept of "full-finger reconstruction of thumb and fingers" and a series of new operation methods: new fingers were designed and assembled by means of using a variety of tissue combination assembly, which changed the traditional method of toe transplantation to reconstruct thumb and fingers, and the method of replacing thumb and fingers by toes was changed to manufacturing new thumb and fingers so that the toes could be retained and the thumb and fingers could be reconstructed with approximately normal shape and function. In recent years, the concept and series of new operation methods of thumb and finger reconstruction have been popularized at home and abroad. This paper focuses on the development of full-finger reconstruction of thumb and fingers.
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Key words:
- Microsurgery /
- Surgical flaps /
- Thumb /
- Finger reconstruction /
- Full-finger reconstruction /
- Toes
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参考文献
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图 1 带蒂移植左足
趾再造左手拇指示意图。1A.术前左手拇指缺损；1B.术前左足正常；1C.将左手拇指残端与左足趾缝合在一起固定；1D.术后左手拇指得以再造；1E.术后左足趾缺损
图 5 游离移植左足
趾腓侧趾腹皮瓣修复右手中指指端软组织缺损的效果。5A、5B.分别为术前右手中指缺损掌侧面、侧面观；5C.术中左足趾腓侧趾腹皮瓣设计；5D.左足趾腓侧趾腹皮瓣修复右手中指术后即刻；5E.术后半年患手与健侧手外形相近；5F.术后半年右手中指背面观,外形良好
图 6 游离移植右足
趾末节骨皮瓣修复左手环指勾甲畸形的效果[48]。6A、6B.分别为术前左手环指勾甲畸形桡侧、掌侧观；6C、6D.分别为右足趾末节骨皮瓣的设计、切取；6E、6F.分别为缝合移植右足趾末节骨皮瓣后供区足背侧、足掌侧观；6G、6H.分别为用克氏针将右足趾末节骨皮瓣固定到环指缺损处中、后；6I.将右足趾末节骨皮瓣移植到环指缺损处缝合后即刻；6J、6K.分别为术后12个月左手环指背侧、掌侧观
图 7 移植左足复合组织瓣再造右手示指指端的效果[48]。7A.右手示指Ⅰ度缺损；7B.左足背侧皮瓣设计；7C.左足跖侧皮瓣设计；7D.切取完成的
甲瓣；7E、7F.分别为术后即刻右手示指掌侧、桡侧观；7G.术后2年右手示指背侧观；7H.术后2年,患手与健侧手外形相近；7I.术后2年,足部供区外观良好
图 8 移植双足
趾甲骨皮瓣再造右手示指与中指的效果[48]。8A.术前右手示、中指Ⅲ度缺损；8B.术后23个月,右手示、中指掌侧外观；8C.术后23个月,右手示、中指背侧外观与健侧相近；8D.术后23个月,右手示、中指握拳活动外观与健侧相近；8E.术后23个月,右手示、中指对指活动外观与健侧相近；8F.术后23个月,双足供区外观良好
图 9 移植右足
趾甲骨皮瓣包绕第2趾近趾间关节串连适当长度的髂骨修复左手示指Ⅴ度缺损的效果[48]。9A.左手示指Ⅴ度缺损术前外观；9B.术前右足皮瓣设计；9C.切取完成的趾甲骨皮瓣；9D.术中皮瓣移植到左手上后X线透视照片；9E.术后即刻左手背侧外观；9F.术后1年右足供区情况与健侧相差不大；9G、9H.分别为术后1年示指掌侧观、屈曲情况
图 10 移植左足
趾甲骨皮瓣与第2趾关节瓣及足底内侧皮瓣重建左手示指的效果。10A.术前左手示指缺损；10B.术前X线片显示左手示指缺损；10C.切取的足底内侧皮瓣；10D.切取的趾甲骨皮瓣及第2趾关节瓣；10E、10F.分别为术后即刻左手掌侧、背侧观；10G、10H.分别为术后45 d X线片展示的左手第3~5指屈曲、所有手指伸直情况；10I.术后1年左手掌侧观；10J、10K.分别为术后1年足底供区、足背供区情况；10L.术后1年左手示指活动情况
图 12 用髂骨、带血管蒂的右足第2趾跖趾关节、带血管蒂的左足第2趾趾骨间关节、左足趾甲骨皮瓣及游离腹股沟皮瓣再造Ⅵ度缺损右手示指的效果[48]。12A.右手示指在掌骨近端平面缺如；12B.术前X线片,见示指自掌骨基底以远缺损；12C.术后24个月,右手背侧外观
图 13 用“手板”模式再造左手第2~5指的效果[48]。13A、13B.分别为术前左手第2~4指缺损掌侧、背侧观；13C、13D.分别为术后3年左手掌侧、背侧观,第2~5指得以重建
图 15 用单指再造模式再造左手第2~4指的效果。15A、15B.分别为术前左手第2~4指缺损背侧、掌侧观；15C、15D.分别为示指再造术后即刻、术后1年；15E、15F.分别为中指、环指再造术后半年；15G、15H.分别为左手所有手指再造术后半年掌侧、背侧观；15I.所有手指再造术后半年双足供区情况
图 16 关节楔形截骨增加手指关节活动度示意图。16A.足趾近趾间关节移植重建手指近指间关节后,手指活动度为70°；16B.锻炼手指,使其过伸40°；16C.在移植的趾间关节的远侧楔形截骨（箭头指示）,使其活动范围达110°；16D.术后手指活动范围达110°
图 17 移植左足
趾甲骨皮瓣修复左手示指缺损后再造供区趾甲的效果。17A.术前左手示指缺损；17B.切取左足趾甲骨皮瓣术中；17C.左手缺损修复术后即刻；17D、17E.分别为术后1年,左手伸直、握拳观；17F.术后1年,供区趾甲通过创面增生瘢痕牵拉和甲床上皮爬行生长变宽
图 19 双侧
趾甲骨皮瓣拼合再造右手示指的效果[48]。19A.右手示指Ⅰ度缺损；19B、19C.分别为在左、右趾上设计带部分末节趾骨的趾甲骨皮瓣；19D、19E、19F.分别为切取的左右趾甲骨皮瓣内侧、外侧、拼接后观；19G.将拼接后趾甲骨皮瓣移植到右手示指并缝合后即刻；19H.左趾甲骨皮瓣（左图）、右趾甲骨皮瓣（右图）切取后供区缝合即刻；19I、19J.分别为术后24个月右手示指伸直、对指观；19K、19L.分别为术后24个月左、右足外观 -
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