拇指背侧远端蒂皮神经营养血管皮瓣修复拇指软组织缺损的临床疗效

CLINICAL EFFECT OF DISTALLY-BASED DORSAL THUMB NEUROCUTANEOUS VASCULAR FLAP ON REPAIR OF SOFT TISSUE DEFECT IN THUMB

目的探讨拇指背侧远端蒂皮神经营养血管皮瓣修复拇指软组织缺损的手术方法及临床效果。方法2006年1月-2007年10月,收治23例拇指软组织缺损患者。男20例,女3例;年龄19～46岁,平均27.5岁。挤压伤1例,电刨伤6例,切割伤及撕脱伤各8例。缺损部位:远节掌侧3例,远节桡背侧3例,尺背侧17例。缺损范围3.3cm×1.2cm～4.2cm×1.2cm。其中18例远端1/2甲床缺失或损伤。受伤至入院时间为1～72h,平均22h。术中以拇指桡背侧远端蒂皮神经营养血管皮瓣修复3例,拇指尺背侧远端蒂皮神经营养血管皮瓣修复20例。皮瓣切取范围为4.0cm×1.6cm～5.0cm×3.0cm。供区直接缝合或中厚皮片植皮修复。结果术后10d3例皮瓣远端1/3表皮坏死,其中2例14d后表皮黑痂脱落,皮瓣成活;1例经换药后皮瓣成活。其余皮瓣及供区植皮均顺利成活,切口Ⅰ期愈合。术后患者均获随访,随访时间10～16个月,平均12.6个月。皮瓣质地软,外形饱满。术后6个月皮瓣两点辨别觉为8～10mm。术后12个月残甲生长18例,其中弯甲或勾甲4例。拇指主动屈伸活动正常;虎口外展达健侧80%或以上者20例,达健侧80%以下者3例。根据自定评价标准,获满意11例,基本满意8例,不满意4例。结论采用拇指背侧远端蒂皮神经营养血管皮瓣修复拇指软组织缺损,手术操作简便,解剖恒定,符合邻近修复原则,术后外形佳,手功能影响小,适用于拇指指端3cm缺损创面修复。

Objective To investigate the surgical methods and clinical results of repairing soft tissue defects in the thumb with distally-based dorsal thumb neurocutaneous vascular flap. Methods From January 2006 to October 2007,23 patients with soft tissue defect in the thumb were treated,including 20 males and 3 females aged 19-46 years old （average 27.5 years old）. The defect was caused by crush injury in 1 case,electric planer accident in 6 cases,incised injury in 8 cases,and avulsion injury in 8 cases. The defect was located on the palmar aspect of the thumb distal phalanx in 3 cases,the dorsal-radial aspect of the thumb distal phalanx in 3 cases,and ulnar or dorsal aspect in 17 cases. The defect size ranged from 3.3 cm × 1.2 cm to 4.2 cm × 1.2 cm. Among them,18 cases were complicated with distal 1/2 nail bed defect or injury. The time between injury and hospital admission was 1-72 hours （average 22 hours）. During operation,the defect was repaired with distally-based dorsal-radial neurovenocutaneous vascular flap of the thumb in 3 cases and distally-based dorsal-ulnar neurovenocutaneous vascular flap of the thumb in 20 cases. The size of those flaps was 4.0 cm × 1.6 cm-5.0 cm × 3.0 cm. The donor site underwent direct suture or split thickness skin graft repair. Results At 10 days after operation,3 cases suffered from the epidermal necrosis in the distal part of the flap,2 of them experienced the exfoliation of dark scab 14 days later and the flap survived,and the flap of the rest one survived after dressing change. The other flaps and the skin graft at the donor site all survived uneventfully. The wounds healed by fi rst intention. All the patients were followed up for 10-16 months （average 12.6 months）. The flaps were soft in texture and full in appearance. The two-point discrimination value 6 months after operation was 8-10 mm. At 12 months after operation,the growth of the residual fingernail was evident in 18 cases,including 4 cases of curved or hook fingernail. Active flexion and extension of the thumb were normal. The abduction of the first web space reached or surpassed 80 percent of the normal side in 20 cases and was below 80 percent of the normal side in 3 cases. The clinical outcomes were satisfactory in 11 cases,approximately satisfactory in 8 cases,and unsatisfactory in 4 cases according to self-designed evaluation system. Conclusion The operative method of repairing the soft tissue defects in the thumb with the distally-based dorsalthumb neurocutaneous vascular flap is simple,stable in anatomy,in line with the principle of proximity,and suitable for repairing thumb tip defect 3 cm in size. It can bring a good postoperative appearance of the thumb and little influence on the hand function.