自体跖趾关节复合组织瓣移植修复创伤性掌指关节缺损

REPAIR OF TRAUMATIC METACARPOPHALANGEAL JOINT DEFECT BY METATARSOPHALANGEAL JOINT COMPOSITE TISSUE FLAP AUTOGRAFT

目的探讨自体第2跖趾关节复合组织瓣移植修复创伤性掌指关节缺损的方法和疗效。方法 2005年6月-2009年12月,对6例创伤性掌指关节缺损采用第2跖趾关节携带趾伸屈肌腱、趾固有神经及跖侧、背侧皮瓣的复合组织瓣进行修复。患者均为男性;年龄18～48岁。机器冲压伤3例,挤压伤2例,其他伤1例。第2、3、4掌指关节缺损各2例,缺损范围1.5cm×1.5cm～3.0cm×2.5cm。均伴有皮肤软组织缺损,缺损范围4cm×2cm～5cm×4cm。5例合并伸肌腱缺损,缺损长度2.5～5.0cm;3例合并屈肌腱断裂;3例合并指总神经损伤。受伤至入院时间2～6h。结果术后复合组织瓣全部成活,创面Ⅰ期愈合;供区植皮成活,切口Ⅰ期愈合。6例均获随访,随访时间1～5年。X线片示术后9～14周骨组织临床愈合良好,移植的跖趾关节与掌、指骨完全愈合。皮瓣外形不臃肿,质地柔软,痛、触觉恢复。末次随访时移植的掌指关节活动度达掌屈50～70°,背伸5～10°。按中华医学会手外科学会上肢部分功能评定试用标准,获优4例,良1例,可1例,优良率达83.3%。足部供区无明显功能障碍。结论应用自体跖趾关节复合组织瓣修复创伤性掌指关节缺损可用一个供区同时修复跖趾关节掌、背侧皮肤及骨、肌腱、神经的缺损,为复杂手外伤提供了一种有效的、可一次性修复的手术方法。

Objective To investigate the surgical method and effectiveness of repairing traumatic metacarpophalangeal joint defect by the composite tissue flap autograft of the second metatarsophalangeal joint.Methods Between June 2005 and December 2009,6 cases（6 fingers） of traumatic metacarpophalangeal joint defect were treated with the composite tissue flap autograft of second metatarsophalangeal joint（containing extensor tendon,flexor tendon,proper digital nerve,planta or dorsal flap）.All patients were males,aged 18-48 years,including 3 cases of mechanical injury,2 cases of crush injury,and 1 case of penetrating trauma.The 2nd,3rd,and 4th metacarpophalangeal joints were involved in defects in 2 cases,repectively,and defects ranged from 1.5 cm × 1.5 cm to 3.0 cm × 2.5 cm in size.All patients had skin and soft tissue defects,and defects ranged from 4 cm × 2 cm to 5 cm × 4 cm in size;and 5 cases complicated by extensor tendon defect（2.5-5.0 cm in length）,3 cases by flexor tendon rupture,and 3 cases by common palmar digital nerve injury.The time from injury to admission was 2-6 hours.Results The composite tissue flaps and skin grafts survived in all cases.All incisions healed by first intention.All patients were followed up 1-5 years.The X-ray films showed good healing between the transplanted metatarsophalangeal joint and metacarpals and phalanges at 9-14 weeks postoperatively.The appearance,colour,and texture of the skin flap were satisfactory,and the senses of pain and touch were recovered.The palmar flexion range of transplanted metacarpophalangeal joints was 50-70°,and the dorsal extension range was 5-10° at last follow-up.According to the functional assessment criteria of upper limb formulated by the Hand Surgery Branch of Chinese Medical Association,the results were excellent in 4 cases,good in 1 case,and fair in 1 case,and the excellent and good rate of 83.3%.No dysfunction of the donor foot was observed.Conclusion The metatarsophalangeal joint composite tissue flap can provide bone,nerve,skin,muscles,and tendons,so it is an effective approach to repair the metacarpophalangeal joint defect and to recover the function of the injured joints in one operation