足部带关节的复合组织瓣移植桥接修复拇、手指断指

Compound flaps of foot with joint transplantation bridging severed thumbs and fingers

目的报道足部带关节的复合组织瓣移植桥接拇、手指断指的手术方法和临床疗效。方法对10例拇、手指完全离断伴有近端指体缺损者，采用游离足部带关节的复合组织瓣桥接再植拇、手指进行修复。4例拇指离断者，采用带足第二跖趾关节、近侧趾间关节的复合组织瓣进行桥接修复3例，1例采用带足第二跖趾关节的复合组织瓣桥接修复，足部供区采用第二跖骨远端截骨截趾、足背游离皮片植皮术；6例手指离断者，采用带足近侧趾间关节的复合组织瓣进行桥接修复，足部供区采用足跖趾关节截趾术。结果术后10例复合组织瓣及再植拇、手指均顺利成活，手部伤口均一期愈合，足部供区除1例愈合不佳。经多次换药后愈合外，其余植皮及截趾区均一期愈合。10例患者获随访6-28个月，平均随访9个月。4例拇指再植者，掌指关节伸-10°-0°，屈曲达20°-50°，3例可以完成与2-5指对指，1例可以完成与示、中指对指，4例可以完成桡侧外展。6例手指再植者，移植的近侧指间关节伸-10°-0°，屈曲30°-90°，平均50°。感觉恢复1例达S_4，2例S_3。，5例S_3，2例为S_2。移植骨关节均愈合（骨性愈合时间为6-16周），未出现骨不连及再骨折。足部供区行走功能无明显影响。按照中华医学会断指再植评定标准评定，属优1例，良8例，差1例，优良率90％。结论采用游离足部带关节的复合组织瓣桥接再植拇、手指的方法，不仅可以最大限度的恢复再植指的外形，还可以获得部分手指功能，满足患者日常生活的需要。

To report the methods and clinical efficacy of bridging severed thumbs and fingers with foot joint compound flaps. Methods Ten patients with completely amputated thumbs and fingers with extensive defects in the proximal phalanx had bridged and repaired by using compositefree flap with joints from foot. Three of 4 cases of thumb amputation were repaired by using composite flaps of the second metatarsophalangeal and proximal interphalangeal joints in foot, and the other was used composite flap of the second metatarsophalangeal joints in foot. Donor sites underwent the second metatarsals distal osteotomy associated with free skin graft. And 6 cases with absent fingers by using compositefree flaps of the proximal interphalangeal joint to repair. The donor site in foot underwent mctatarsopbalangeal and toe joints osteotomy. Results All flaps and replanted thumbs and fingers survived. Hand wounds recovered by primary repair. Donor site in foot all healed by primary repair except for 1 case, which healed after several dressing changes. All 10 cases were followed-up from 6 to 28 months, averaged of 9 months. The metacarpophalangeal joint of 4 replanted thumbs extension between -10° and 0°, and flexion between 20° and 50°. The function of fullfield digital mammography recovered well in 3 replanted thumbs, as weU as the function of thumbmiddle in the other. Three of them could completely 2-5 fingers tapping, one case could complete middle finger tapping, four cases could complete radial abduction. The proximal interphalangeal joints of 6 replanted fingers extension between -10° and 0°, and flexion between 30° and 90°, averaged of 50°. Sensory recovery of 1 case reached S_4, two cases reached S_3, five cases reached S_3, and 2 cases of S_2. All replanted bones and jointshealed after transplantations （bone healing time was 6 to 16 weeks）, with no occurrence of re-fracture nor nonunion. Walking function was not significantly affected. According to the evaluation criteria of replanted severed fingers by Chinese Medical Association, one was excellent, eight were good, and 1 was poor. The excellent and good rate was 90%. Conclusion Repairing amputated thumbs and fingers with foot joint compound flaps could not only maximize the recovery of replanted fingers shape, but also get some function, which to meet everyday needs of patients.