髂骨皮瓣修复手掌部毁损伤

Vascularized iliac osteocutaneous flap for management of mutilated hand

目的探讨应用吻合旋髂深动脉的髂骨皮瓣一期修复手掌部毁损伤所致多根掌骨复合组织缺损的疗效。方法1996年以来，对8例手掌部毁损伤所致多根掌骨复合组织缺损，采用吻合旋髂深动脉的髂骨皮瓣重建手掌，并一期修复肌腱、神经。其中2根掌骨缺损3例，3根3例，4根2例。6例肌腱、神经缺损在2～3cm以内，通过短缩植骨，获得肌腱、神经的直接缝合；1例2～5掌骨缺损通过一期“Y”形截骨，增加骨承载面，减小了骨瓣切取宽度；1例通过传统骨移植单独重建第一掌骨，获得了拇指单独活动功能；2例合并掌骨头缺损者一期行掌指关节成形术。结果8例骨皮瓣全部存活，7例伤口I期愈合，1例因术后皮瓣肿胀，拆除部分缝线，获得Ⅱ期愈合。术后随访1～3年，临床骨愈合时间为3～5周，全部获得骨性愈合。供区无明显并发症。术后手功能评定：优1例，良5例，可1例，差1例；优良率为75％。结论应用吻合旋髂深动脉的髂骨皮瓣移植重建手掌，并一期修复肌腱和神经，可以较好地恢复手的外形和功能，是手掌毁损伤修复重建的一种有效治疗方法。

Objective To investigate the treatment effect of one stage reconstruction of mutilated hand with multiple metacarpal composite tissue defect using vascularized iliac osteecutaneous flap, palm tissue defect accompanied with multiple metacarpal bones defect by iliac flap through anastomosing deep iliac ciroumflex artery. Methods Since 1996, 8 patients with serious mutilating injury of the palm that resulted in multiple metacarpal bone and soft tissue defect underwent transfer of lilac osteocutancous flap through anastomosing the deep lilac cimumflex artery. Tendons and nerves were also repaired in the same stage. In 3 cases 2 metacarpal bones were missing, 3 cases had 3 metacarpal bones gone, while the other 2 cases with 4 metacarpal bone defect. The tendon and nerve defect in 6 eases were shorter than 2-3 cm and direct repair was achieved by shortening the bone graft. One stage ＂ Y＂ osteotomy was done in 1 case of 2-5 metacarpal bone defect to incroase bony contact surface and decrease the size of harvested iliac bone graft. One case underwent conventional iliac bone graft to the first metacarpal to restore independent thumb movement. Arthroplasty of the metacarpophalangeal joint was done in 2 cases with metacarpal head defect. Results All osteocutaneous flaps survived. Wound healed in one-stage in 7 cases, and healed in second stage in 1 case because of swelling. During 1-3 years follow-up post-operatively, the clinical bony union time was 3 to 5 weeks. There was no complication of the donor site. Hand function was graded excellent in 1 case, good in 5 cases, fair in 1 case, and bad in 1 case one year post-operatively. Conclusion Reconstruction of mutilated palm by transfer iliac osteocutaneous flap through anastomosing deep lilac circumflex artery and repairing tendons and nerves in one-stage can restore acceptable hand appearance and function. It is an effective treatment for mutilating hand injuries.