游离穿支皮瓣联合<inline-graphic id="IG1" xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="alternativeImage/B539784D-8A4B-489a-9125-2F83D004F977-F501c.png"/>趾移植修复拇指毁损合并手部热压伤的疗效

陈俊杰; 李森; 周树萍; 王焕鹏; 邢新风; 石攀成; 郑立武; 常超楠; 张东; 李士民

doi:10.3760/cma.j.cn501225-20250130-00046

游离穿支皮瓣联合趾移植修复拇指毁损合并手部热压伤的疗效

doi: 10.3760/cma.j.cn501225-20250130-00046

解放军联勤保障部队第988医院烧伤整形科,郑州　　450007

基金项目:

河南省医学科技攻关计划联合共建项目 LHGJ20240988, LHGJ20240983

详细信息

通讯作者:
李士民,Email：sszxwk988@163.com

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出版历程
- 收稿日期: 2025-01-30

Efficacy of free perforator flap combined with great toe transplantation in repairing thumb damage combined with thermal crush injuries in the hand

Department of Burns and Plastic Surgery, the 988th Hospital of Joint Logistics Support Force of PLA, Zhengzhou 450007, China

Funds:

Joint Construction Project of Medical Science and Technology Research Program of Henan Province of China LHGJ20240988, LHGJ20240983

More Information

Corresponding author: Li Shimin, Email: sszxwk988@163.com

摘要

摘要: 目的探讨游离穿支皮瓣联合趾移植修复拇指毁损合并手部热压伤的治疗效果。方法该研究为回顾性观察性研究。2014年5月—2024年3月,解放军联勤保障部队第988医院收治7例符合入选标准的拇指毁损合并手部热压伤患者,其中男５例、女2例,年龄25~46岁。清创后,拇指毁损分度为Ⅱ度者2例、Ⅲ度者3例、Ⅳ度者2例。采用趾移植再造毁损拇指,随后测得患手创面面积为9.0 cm×4.0 cm~18.0 cm×10.0 cm；采用游离股前外侧穿支皮瓣移植修复5例患者手部创面,游离腹壁下动脉穿支皮瓣移植修复2例患者手部创面。切取的穿支皮瓣面积为9.5 cm×4.5 cm~19.0 cm×11.0 cm。将穿支皮瓣及移植趾的动脉与患手桡动脉吻合,静脉分别与桡静脉、头静脉或受区匹配静脉吻合；同时将穿支皮瓣携带的皮神经与受区桡神经浅支或正中神经掌侧皮支吻合。对于皮瓣供区创面,采用直接缝合或皮片移植的方式进行修复。术后,观察再造拇指及穿支皮瓣成活情况,观察供受区创面愈合情况。术后随访时,检查再造拇指的骨质愈合情况,同时观察再造拇指外形及功能；观察穿支皮瓣外观并检测两点辨别觉距离及感觉恢复情况；观察移除趾后的足部功能。末次随访时,参照中华医学会手外科学会拇、手指再造功能评定试用标准评定患者再造拇指功能。结果术后再造拇指及穿支皮瓣均成活。2例患者穿支皮瓣缝合口因脂肪液化及皮缘炎症而延迟愈合；其余患者受区创面均愈合良好。供区创面均愈合良好。随访8~18个月显示,再造拇指的骨质愈合良好,外形与健侧接近,对掌、对指功能良好,能满足日常生活工作需求；穿支皮瓣外观良好,两点辨别觉距离为0.7~1.6 cm,感觉恢复良好；移除趾后的足部行走、站立功能正常。末次随访时,再造拇指功能评定为优者3例、良者3例、可者1例。结论游离穿支皮瓣联合趾移植是治疗拇指毁损合并手部热压伤的理想方法,具有在修复手部复杂创面的同时完成拇指的再造,最大限度恢复手部功能等优点。
- 烧伤 /
- 穿支皮瓣 /
- 手 /
- 拇指 /
- 显微外科手术 /
- 热压伤 /
- 毁损伤 /
- 趾移植 /
- 创面修复
Abstract: Objective To explore the efficacy of free perforator flap combined with great toe transplantation in repairing thumb damage combined with thermal crush injuries in the hand. Methods This study was a retrospective observational study. From May 2014 to March 2024, seven cases (5 males and 2 females, aged from 25 to 46 years) with thumb injuries combined with thermal crush injuries in hands were admitted to the 988^th Hospital of Joint Logistics Support Force of the PLA. After surgical debridement, the thumb defects were classified as grade Ⅱ in 2 cases, grade Ⅲ in 3 cases, and grade Ⅳ in 2 cases. The great toe transplantations were adopted to reconstruct the damaged thumb, and subsequent measurements indicated that the wound area of the affected hand ranged from 9.0 cm×4.0 cm to 18.0 cm×10.0 cm. Hand wounds were repaired in 5 cases by free anterolateral thigh perforator flap transplantations and in 2 cases by free deep inferior epigastric artery perforator flap transplantations. The harvested perforator flap area ranged from 9.5 cm×4.5 cm to 19.0 cm×11.0 cm. The arteries of the perforator flap and transplanted great toe were anastomosed to the radial artery of the affected hand, while the veins were anastomosed to the radial vein, cephalic vein, or other matching veins in the recipient area. Meanwhile, the cutaneous nerves carried by the perforator flap were anastomosed with the superficial branch of the radial nerve or the palmar cutaneous branch of the median nerve in the recipient region. The wounds in the flap donor sites were closured by suture or repaired by skin grafting. After the surgery, the survival status of the reconstructed thumb and the perforator flap were observed, as well as the healing conditions at the donor and recipient sites. During the postoperative follow-up, the bone healing condition of the reconstructed thumb was examined, and the appearance and function of the reconstructed thumb were observed. The appearance of the perforator flap was observed, the two-point discrimination distances and sensory recovery were detected. The function of the foot after the removal of the great toe was also observed. At the last follow-up, the functions of the reconstructed thumbs of patients were evaluated with reference to the trial standard for the evaluation of thumb and finger reconstruction function formulated by the Hand Surgery Society of the Chinese Medical Association. Results Both the reconstructed thumb and the perforator flaps survived after the operation. The sutured sites of the perforator flaps in 2 cases had delayed healing due to fat liquefaction and skin edge inflammation. The wounds of the recipient areas of the remaining cases healed well. All the wounds of the donor areas healed well. During the follow-up period of 8 to 18 months, the bone of the reconstructed thumb healed well, with its appearance being similar to that of the healthy side. The opposition and apposition functions of the reconstructed thumb were satisfactory, adequately meeting the demands of daily life and work. The appearance of the perforator flap was good, the two-point discrimination distance was 0.7-1.6 cm, and the sensation recovered well. The walking and standing functions of the foot were normal after the removal of the great toe. At the last follow-up, the functional evaluation results of the reconstructed thumbs of all patients were as follows: excellent in 3 cases, good in 3 cases, and fair in 1 case. Conclusions The free perforator flap in combination with the great toe transplantation is an ideal method for treating thumb damage combined with thermal crush injuries in the hand. It has the advantages of repairing complex wounds in the hand while completing thumb reconstruction, and restoring the hand function to the maximum extent.
- Burns /
- Perforator flap /
- Hand /
- Thumb /
- Microsurgery /
- Thermal crush injury /
- Devastating injury /
- Great toe transplantation /
- Wound repair
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参考文献(40)

[1]	焦涛, 任孝燕, 孙荣涛, 等. 第1足趾甲瓣游离移植修复手部拇指背侧热压伤十例[J].中华烧伤杂志,2015,31(6):456-457. DOI: 10.3760/cma.j.issn.1009-2587.2015.06.017.
[2]	苏日宝, 王培吉, 崔满意, 等. 改良的骨间后动脉逆行岛状皮瓣修复手背部热压伤的临床疗效[J].中华显微外科杂志,2018,41(2):125-128. DOI: 10.3760/cma.j.issn.1001-2036.2018.02.006.
[3]	TsaiYJ, CarvajalCF, FloresNM, et al. Reconstruction of pediatric hand injuries caused by automatic cup-sealing machines in Taiwan[J]. J Int Med Res, 2019,47(11):5855-5866. DOI: 10.1177/0300060519874540.
[4]	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.
[5]	XuefengZ, JianG, JiayueD, et al. Clinical effect of thumb finger reconstruction using dorsal foot flap transplant for treating thumb defects[J]. Med Hypotheses, 2020,134:109435. DOI: 10.1016/j.mehy.2019.109435.
[6]	Morales-PerezMJ, Gallardo-CaleroI, Rivas-NicollsD, et al. Reconstruction of COVID-19 vasculitis-related thumb necrosis with a microsurgical free flap[J]. Microsurgery, 2021,41(4):393-395. DOI: 10.1002/micr.30719.
[7]	FuseY, YamamotoT, KageyamaT, et al. Domino free flap transfer using a superficial circumflex iliac artery perforator flap for the toe flap donor site[J]. Ann Plast Surg, 2022,88(3):293-297. DOI: 10.1097/SAP.0000000000002948.
[8]	YamamotoT. Day microsurgery: further application of free flap transfer as an ambulatory surgery[J]. J Plast Reconstr Aesthet Surg, 2023,84:567-573. DOI: 10.1016/j.bjps.2023.06.055.
[9]	王增涛,刘焕龙,郝丽文,等. 拇与手指再造新进展[J].中华烧伤与创面修复杂志,2025,41(2):109-119.DOI: 10.3760/cma.j.cn501225-20240814-00305.
[10]	HouZ, ZouJ, WangZ, et al. Anatomical classification of the first dorsal metatarsal artery and its clinical application[J]. Plast Reconstr Surg, 2013,132(6):1028e-1039e. DOI: 10.1097/PRS.0b013e3182a97de6.
[11]	潘达德,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(3):130-135. DOI: 10.3760/cma.j.issn.1005-054X.2000.03.003.
[12]	胡雷鸣, 欧学海, 魏登科, 等. 𧿹甲皮瓣联合腓动脉穿支皮瓣游离移植再造拇指并修复足部供区15例[J].中国修复重建外科杂志,2020,34(5):667-668.DOI: 10.7507/1002-1892.201908023.
[13]	庄振华,黄平,王运增,等. 带趾骨拇甲瓣联合游离股前外侧皮瓣修复严重手部大面积软组织缺损伴拇指部分缺损八例[J]. 中华烧伤杂志,2013,29(6):565-567. DOI: 10.3760/cma.j.issn.1009-2587.2013.06.018.
[14]	LiuY, MillerEA, WeeCE, et al. Osteoplastic thumb reconstruction in the immediate setting: a case series[J]. Plast Reconstr Surg Glob Open, 2022,10(6):e4385. DOI: 10.1097/GOX.0000000000004385.
[15]	WeintraubMD, HansfordBG, StilwillSE, et al. Avulsion injuries of the hand and wrist[J]. Radiographics, 2020,40(1):163-180. DOI: 10.1148/rg.2020190085.
[16]	丁治红, 王和驹, 李有斌, 等. 甲瓣联合髂骨移植在I~Ⅱ度拇指缺损全形再造术中的临床应用[J].中华显微外科杂志,2022,45(2):197-200. DOI: 10.3760/cma.j.cn441206-20211216-00297.
[17]	Jafari KafiabadiM, EbrahimpourA, AyatizadehSH, et al. Temporary ectopic banking as a treatment option for mangled thumb: a case report[J]. J Med Case Rep, 2025,19(1):35. DOI: 10.1186/s13256-025-05058-9.
[18]	HouC, ZhangA, YuX, et al. Reconstruction of fully shaped fingers using a free great toe nail flap combined with a second toe tissue flap[J]. Int Wound J, 2022,19(6):1389-1396. DOI: 10.1111/iwj.13732.
[19]	孟红旗, 田恒, 李娜, 等. 骨间掌侧血管穿支营养的尺侧腕上皮瓣一例[J].中华手外科杂志,2023,39(6):569-570. DOI: 10.3760/cma.j.cn311653-20221012-00268.
[20]	杨伟渊, 袁云发, 秦建华, 等. 腹部带蒂皮瓣修复手外伤后感染创面并骨外露的临床效果[J].中华医院感染学杂志,2023,33(13):2005-2009. DOI: 10.11816/cn.ni.2023-221984.
[21]	YuanC, LiuH, ZhangH, et al. Reconstruction of thumb pulp defects using free lateral great toe flaps[J]. J Hand Surg Am, 2021,46(5):421.e1-421.e7. DOI: 10.1016/j.jhsa.2020.10.004.
[22]	YangJ, YuL, MengF, et al. Role of microsurgical techniques combined with Ilizarov techniques in limb salvage and functional reconstruction of thermal-crush injuries of the hand: a case report[J]. Exp Ther Med, 2024,28(1):291. DOI: 10.3892/etm.2024.12580.
[23]	中国老年医学学会烧创伤分会, 中国生物材料学会烧创伤创面修复材料分会, 中国医师协会创面修复专业委员会. 热压伤创面临床诊疗全国专家共识(2023版)[J].中华烧伤与创面修复杂志,2023,39(3):201-208. DOI: 10.3760/cma.j.cn501225-20220608-00227.
[24]	ShenYM, QinFJ, DuWL, et al. Extended paraumbilical perforator flap pedicled with the inferior epigastric artery for coverage of type Ⅲ circumferential electrical burns of the wrist[J]. J Burn Care Res, 2023,44(6):1339-1348. DOI: 10.1093/jbcr/irad108.
[25]	GrazianoFD, LuJ, SbitanyH, et al. Fifty years of free tissue transfer: the past, present and future of microsurgical reconstruction[J]. ANZ J Surg, 2025,DOI: 10.1111/ans.70032.
[26]	PengP, GuoQ, TangY, et al. Replantation of digit-tip amputation caused by crush injuries with supermicrosurgery technique[J]. Eur J Trauma Emerg Surg, 2024,50(4):1497-1502. DOI: 10.1007/s00068-024-02485-z.
[27]	ShariatzadehH, MotalebiM, SoltaniF, et al. Four decades of hand microsurgery in Iran: a bibliographic analysis[J]. J Educ Health Promot, 2022,11:418. DOI: 10.4103/jehp.jehp_134_22.
[28]	BanerjeeA, JouE, WongKY. Supermicrosurgery: past, present and future[J]. Br J Hosp Med (Lond), 2023,84(10):1-10. DOI: 10.12968/hmed.2022.0482.
[29]	李雷,巨积辉,崔龙杰,等. 甲皮瓣联合足背皮瓣移植并髂骨植骨拇指再造5例[J].中华手外科杂志,2016,32(5):325-328. DOI: 10.3760/cma.j.issn.1005-054X.2016.05.002.
[30]	潘勇卫, 田文, 田光磊, 等. 改良游离母甲皮瓣移植再造拇指[J].中华手外科杂志,2005,21(2):79-82. DOI: 10.3760/cma.j.issn.1005-054X.2005.02.005.
[31]	杜伟伟, 唐林峰, 李友, 等. 带足背皮瓣的第二足趾再造拇指缺损并重建虎口[J].中国美容整形外科杂志,2024,35(7):408-410. DOI: 10.3969/j.issn.1673-7040.2024.07.007.
[32]	韩明通,何旭,王博,等. 应用皮瓣修复游离足趾移植后供区创面[J/CD]. 中华移植杂志(电子版),2011,5(1):47-50. DOI: 10.3877/cma.j.issn.1674-3903.2011.01.011.
[33]	郝丽文, 陈超, 王增涛. 骨延长技术在手指缺损全形再造中的应用效果观察[J].山东医药,2018,58(44):58-60. DOI: 10.3969/j.issn.1002-266X.2018.44.016.
[34]	张宁, 贺椿媛, 周可佳, 等. 3D打印骨和皮模型在拇指全形再造术中的临床应用[J].中华显微外科杂志,2024,47(2):154-159. DOI: 10.3760/cma.j.cn441206-20240109-00010.
[35]	王增涛, 蔡锦方, 曹学成, 等. 趾腓侧皮瓣嵌入第二足趾改形法再造拇手指[J].中华手外科杂志,2002,18(1):20-22. DOI: 10.3760/cma.j.issn.1005-054X.2002.01.007.
[36]	ForteAJ, MaitaKC, Torres-GuzmanRA, et al. Great toe transplantation[J]. Semin Plast Surg, 2022,36(4):243-252. DOI: 10.1055/s-0042-1758689.
[37]	陆声榆,谭海涛,江建中,等. 第二足趾移植再造手指术后整形的临床分析[J]. 中华显微外科杂志,2012,35(4):329-330. DOI: 10.3760/cma.j.issn.1001-2036.2012.04.024.
[38]	彭龙, 刘承伟, 董书男, 等. 游离股前外侧穿支皮瓣修复足跟部大面积软组织缺损18例[J].中华显微外科杂志,2021,44(2):202-205. DOI: 10.3760/cma.j.cn441206-20201125-00396.
[39]	欧昌良, 罗旭超, 周鑫, 等. 游离腹壁下动脉穿支皮瓣联合旋髂浅动脉髂骨瓣修复足部复合组织缺损[J].中华显微外科杂志,2023,46(2):193-196. DOI: 10.3760/cma.j.cn441206-20220924-00201.
[40]	HuangY, LuY, CaoJ, et al. A comparison between anterolateral thigh perforator flap and abdominal pedicle flap in repair of hand injuries and tissue defects[J]. J Pak Med Assoc, 2023,73(4):876-878. DOI: 10.47391/JPMA.6606.

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图 1 游离股前外侧穿支皮瓣联合趾移植修复例1患者右手拇指Ⅲ度毁损合并热压伤创面的效果。1A.入院时,可见右手拇指、虎口及腕部皮肤呈皮革样；1B.彻底清创后右手拇指呈Ⅲ度毁损；1C.移植术前,设计趾及足背切口背侧观；1D.对切取后的趾进行缩容处理后即刻；1E.游离切取股前外侧穿支皮瓣后即刻；1F.手部修复完成后即刻；1G.足部供区封闭后即刻；1H.术后3周患手背面观；1I.术后10个月再造拇指外观及功能良好；1J.术后10个月患手可握笔写字

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图 2 游离腹壁下动脉穿支皮瓣联合趾移植修复例2患者右手拇指Ⅱ度毁损合并热压伤创面的效果。2A.入院时,可见右手拇指、鱼际处皮肤呈皮革样,周围有水疱形成；2B.彻底清创后右手拇指呈Ⅱ度毁损；2C.切取趾术中；2D.切取游离腹壁下动脉穿支皮瓣术中；2E.对切取后的趾进行缩容处理后即刻；2F.游离切取腹壁下动脉穿支皮瓣后即刻；2G、2H.分别为手部修复完成后即刻掌面观和侧面观；2I.术后3周手部掌面观；2J.术后12个月患手可握笔写字

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