组合组织移植修复复杂性手外伤

COMBINED TISSUE TRANSPLANTATION FOR COMPLICATED HAND INJURY

目的对2～5块组织组合移植修复复杂性手外伤的组合形式和手术方式进行探讨。方法对1989年12月～2002年12月治疗的305例进行分析和总结。其中2块组织组合移植214例,组合形式:足趾加皮瓣、双侧第2足趾移植、双皮瓣组合移植;3块组织组合移植75例,组合形式:双侧第2足趾加皮瓣、双皮瓣加足趾、3块皮瓣组合移植;4块组织组合移植11例,组合形式:双皮瓣加双足趾、足趾加3块皮瓣、4块皮瓣组合移植;5块组织组合移植5例,组合形式:同一血管蒂的口止母甲瓣和第2足趾、对侧第2足趾、双侧股前外侧皮瓣组合移植。修复原则:先修复拇指,拇指脱套伤采用口止母趾甲皮瓣,拇指缺损用第2足趾移植;移植对侧第2足趾建立与拇指对指对捏功能;根据创面的大小用1块或2块皮瓣修复。供区皮瓣的选择,大面积用股前外侧皮瓣,小面积用上臂外侧皮瓣。结果305例722个组织,其中足趾移植351个,皮瓣移植371块。术后共14个组织坏死,其中第2足趾坏死6趾,皮瓣移植8块,其余移植组织全部成活,移植组织成活率达98.1%。251例经1～7年,平均2.6年随访。所有患者生活均能自理,再造的拇手指恢复对指对掌功能,感觉可达6～14mm,2例级缺损由于大鱼际肌功能丧失,再造拇指时,未固定对掌位,只有夹持功能。所有移植皮瓣恢复保护性感觉S2,其中有56例因皮瓣臃肿分别作切开或闭合去脂术。供区创面期愈合285例,期愈合20例,其中12例为口止母甲瓣切取后供区植皮部分坏死,有2例口止母趾末节坏死。8例股前外侧皮瓣创面植皮有部分坏死,经二期植皮后成活。结论根据创伤情况采用不同的组合形式。理想的功能既取决于手术,同时也需早期各种理疗康复。组合组织移植是修复复杂性手外伤的最佳方法。

Objective To investigate the effect of combined types in treating cases with 2 to 5 tissues transplantation. Methods 305 cases treated from December 1989 to December 2002 were analyzed and summarized. 214 cases were constructed with 2 combined tissues transplantation, the combined types were:toe combined flap,the second toe at both sides transplanted,2 flaps combined transferred; 75 cases were constructed with 3 combined tissues transplantation,the combined types were:the second toe at both sides combined flap,2 flaps combined toe,3 flaps combined transferred;11 cases were constructed with 4 combined tissues transplantation, the combined types were:2 flaps combined 2 toes,1 toes combined 3 flaps,4 flaps combined transferred; 5 cases were constructed with 5 combined tissues transplantation, the combined type was:the wrap flap and the second toe with 1 vascular pedicle and another second toe combined bilateral femoris anterior flaps were transferred.The principles of repair were:the thumb was reconstructed first,the wrap round flap was used for the thumb's skin,the second toe transplantation was used for the thumb defect.The opposite toe was transferred to finger to reconstruct the pinch function.1 or 2 flaps were selected for repair according to the area of damage. The anterolateral thigh flaps were used for the large areas and the lateral arm flaps were used for the small areas in selecting the donor area. Results Of the 722 tissues in 305 cases, 14 of them were necrosis, in which the toe were 6 and the flap were 8,and other transferred tissues all survived, the survival rate of tissue transplantation was 98.1%.251 cases were followed up for 1 year to 7 years(2.6 years in average).All the patients could care themselves in daily life. The pinch and opposition functions of the constructed thumbs and fingers were recovered,the two-point discrimination was 6 to (14 mm,)but 2 cases recovered adduction function only because the thumb was 6 degree defect without the thenar muscle and did not fix the reconstructed thumb in opposite side in operation.All transplanted flaps recovered protecting sensory with S_2,56 flaps required plastical operation because of their swelling appearance.The donor areas gained primary stage heal in 285 cases,20 cases gained secondary stage heal, in which part grafted skin necrosis in donor of wrap round flap were 12 cases,the distal of donor big toe necrosis were 2 cases and grafted skin necrosis in donor of anterolateral thigh flap were 8 cases and skin grafted were sucessful.( Conclusion Different) combined types can be used according to the traumatic situation. Surgical operation and early rehabilitation is conducive to the final function.Combined tissue transplantation is the best way to repair complicated hand injuries.