足部寄养指与足背皮瓣联合移植再造拇指及修复手部皮肤缺损

TEMPORARY ECTOPIC IMPLANTATION OF AMPUTATED FINGERS AND DORSALIS PEDIS FLAPS FOR THUMB RECONSTRUCTION AND SKIN DEFECT REPAIR OF HANDS

目的探讨利用足部寄养指与足背皮瓣联合移植再造拇指及修复手部皮肤软组织缺损的可行性。方法 2006年2月-2012年2月,收治9例拇指离断伤且无再植适应证患者。男7例,女2例;年龄20～45岁,平均35岁。致伤原因:爆炸伤1例,冲床轧伤1例,搅拌机绞伤1例,齿轮挤压伤3例,重物砸伤3例。伤后2～5 h行一期手术,将拇指寄养于足背;手部清创缝合后拇指Ⅲ度1例,Ⅳ度3例,Ⅴ度5例。寄养指成活1～4个月后,行二期足部寄养指及足背皮瓣联合移植再造拇指及修复手部皮肤软组织缺损,手部皮肤缺损范围5 cm×4 cm～7 cm×6 cm,足背皮瓣切取范围6 cm×5 cm～8 cm×7 cm;供区游离植皮修复。结果一期术后第1天1例发生动脉危象,行血管探查术后危象解除;其余拇指均顺利寄养成活。二期术后再造拇指及足背皮瓣均顺利成活;足部供区植皮均成活。患者术后均获随访,随访时间1～4年,平均2.8年。再造拇指外观良好,对指及对掌功能满意。术后1年根据中华医学会手外科学会断指再植功能评定试用标准评分为73～91分,平均84分;其中优7例,良2例,优良率达100%。结论利用足部寄养指与足背皮瓣联合移植可再造拇指同时修复手部皮肤软组织缺损。

Objective To investigate the feasibility of temporary ectopic implantation of amputated fingers and dorsalis pedis flaps for thumb reconstruction and skin defect repair of the hand. Methods Between February 2006 and February 2012, 9 patients with thumb amputation having no replanted condition were treated. There were 7 males and 2 females with an average age of 35 years （range, 20-45 years）. The injury causes included explosive injury in I case, puncher injury in 1 case, stiring machine injury in 1 case, gear injury in 3 cases, and heavy pound injury in 3 cases. At 2-5 hours after injury, one-stage temporary ectopic implantation of amputated finger to foot was performed. After debridement, thumb defect was rated as degree III in 1 case, as degree IV in 3 cases, and as degree V in 5 cases. When amputated fingers survived completely after 1-4 months, the amputated finger was replanted to its anatomic position, skin defect was repaired with dorsalis pedis flap. The area of skin defect ranged from 5 cm × 4 cm to 7 cm × 6 cm. The area of flaps ranged from 6 cm × 5 cm to 8 cm × 7 cm. The donor site was repaired by the skin grafting. Results Arterial crisis occurred in 1 case after 1 day of one-stage operation, and was cured after vascular exploration, and the amputated fingers survived in the others. The reconstructed thumbs and flaps survived after two-stage operation, and the skin graft at donor site survived. The patients were followed up 1-4 years （mean, 2.8 years）. The reconstructed thumbs had good appearance and satisfactory opposition and finger-to-finger functions. According to the standard functional evaluation issued by Hand Surgery Association of Chinese Medical Association, the scores of survival fingers were 73-91 （mean, 84）; the results were excellent in 7 cases and good in 2 cases with an excellent and good rate of 100%. Conclusion Temporary ectopic implantation of amputated finger to foot combined with dorsalis pedis flap can be used to reconstruct thumb and repair skin defect of the hand.