携带皮瓣的胸小肌移植重建拇对掌功能的解剖与临床研究

Anatomical and clinical study on thumb opponenplasty using partial pectoralis minor muscle transfer along with a skin flap

目的研究携带皮瓣的胸小肌移植重建拇对掌功能术式的解剖基础及临床治疗效果。方法在10具20侧成人胸部标本及8例上肢标本上，对胸外侧动脉的分支、分布等进行解剖学观测，寻找胸外侧动脉发出的皮动脉和胸小肌支；观察胸内侧神经及尺神经深支分支特点，比较相关神经有髓神经纤维数目，确定手术过程中的神经缝接。依据解剖研究结果，按新的手术方式施行临床手术治疗7例，术后随访拇对掌功能的恢复情况。结果解剖研究结果显示：胸外侧动脉较恒定地发出皮支和肌支分别营养胸外侧皮肤和胸小肌，这种血管构造的出现率为80％，切取胸小肌时以胸内侧神经作为供体神经，以第三肋间隙与锁骨中线交点为标记寻找该神经；尺神经深支中R、L4肌支与胸内侧神经缝合最为匹配。临床手术治疗7例，术后随访6～12个月，拇对掌功能恢复良好，肌力均达到№以上，大鱼际部外形满意。结论携带皮瓣的胸小肌移植重建拇对掌功能这一术式有其临床解剖基础，移植手术能达到恢复对掌功能的要求，扩大了胸小肌移植重建拇对掌功能的适应证。

Objective To explore the anatomic feasibility of transferring pectoralis minor muscle along with a skin flap to reconstruct thumb opposition and evaluate the treatment outcomes. Methods Anatomic dissection was carried out in 20 sides of 10 adult cadavefic thoracic parts and 8 upper limb specimens. Branches of the lateral thoracic artery and their distributions were investigated. The cutaneous branches and pectoralis minor muscular branches from the lateral thoracic artery were observed. The medial pectoral nerve and the deep branches of the ulnar nerve were compared in regard to the branching patterns and the number of myelinated nerve fibers to guide the possible nerve coaptation during the reconstructive surgery. Based on the observed data, 7 cases with scar contraeture in thenar that led to loss of opposition function were treated with pectoralis minor muscle transfer along with a skin flap. Functional recovery of thumb opposition was evaluated during postoperative follow-up. Results The lateral thoracic artery had relatively constant cutaneous branches and pectoralis minor muscular branches. The occurrence rate was 80% （16/20） in our anatomical dissections. The medial pectoral nerve could be harvested along with the pectoralis minor mnscle, which could be found at the junction of the midclavicular line and the third intercostal space. When sutured to the P3 and L, of the deep branches of the ulnar nerve, the medial pectoral nerve had the best size-match with the recipient nerve. The 7 clinical cases were follow-up for 6 to 12 months. All patients recovered good thumb opposition with muscle strength of M4 or higher. The shape of thenar eminence was satisfactory. Conclusion Transfer of pectoralis minor muscle along with a skin flap for thumb opponenplasty has anatomical basis. Its clinical application can lead to satisfactory functional restoration and thus expands the indications of this myocutaneous flap.