改良髂骨骨皮瓣游离移植治疗掌背复合组织缺损

Modified iliac osteocutaneous free flap in the treatment of loss of metacarpal bone and soft tissue

目的总结游离改良的以旋髂浅动脉为蒂的髂骨骨皮瓣重建掌背骨与软组织缺损体会。方法2009年3月-2012年3月，应用骨皮瓣修复掌背复合组织缺损7例，平均年龄42．9岁。伤肢均为右手．合并不同程度伸肌腱损伤2例：合并腕骨骨折、脱位2例；掌指关节损伤3例；指骨骨折3例。受伤至再手术时间平均为18．6d。术后7d开始功能练习。定期复查，了解植骨愈合、关节活动度、握力大小、皮瓣感觉恢复及供区副损伤，完成患肢手臂肩残疾问卷表及供区可视疼痛评估表。结果本组皮瓣全部成活．5例甲级愈合，2例乙级愈合。平均骨愈合时间：植骨远端2．3个月，近端2．7个月。随访12～24个月，腕关节平均掌屈38．6°，背伸42．9°，尺偏21．4°，桡偏22．9°。受累掌指关节平均活动度35．7°。患侧平均握力13．9kg。3例皮瓣平均静态两点辨别觉13．7mm，余皮瓣仅恢复深触觉。平均手臂肩残疾问卷评分12．1分。所有患者术后2周可行走，术后3个月轻微疼痛1例，术后1年供区瘢痕平软，无疼痛。结论游离改良的以旋髂浅动脉为蒂的髂骨骨皮瓣可成功治疗掌背部骨与软组织缺损，供区损伤较小。

Objective To investigate the outcomes of reconstruction of metacarpal bone and soft tissue defect by modified iliac osteocutaneous flap based on the superficial circumflex iliac artery. Methods Between March 2009 and March 2012, seven patients with the mean age of 43 years old were treated. All injured hands were right. All patients had injured extensor tendon, and two of them required tendon graft. Two patients had combined fracture and dislocation of the carpus, three patients had injured metacarpophalangeal joints, and three patients had phalanx fracture. The surgical procedure included radical debridement followed by osteocutaneous flap transferring. Patients were examined with regard to bone union, range of joint motion, grasp, recovery of flap sensation, and morbidity at the donor site. Questionnaires including Disabilities of Ann and Shoulder, and pain on a visa] analog scale at the donor site were completed by patients. Results There was no flap loss. All wounds healed primarily. The distal bone union ocurred at the mean period of 2.3 months and the proximal bone union ocurred at the mean period of 2.7 months. During the follow-up period from 12 to 24 months, a mean motion of 38.6 degrees of wrist flexion, 42.9 degrees of wrist extension, 21.4 degrees of ulnar deviation, and 22.9 degrees of radial deviation was achieved. The mean motion of affected metacarpop-halangeal joint was 35.7 degrees. Mean lesion grasp strength was 13.9kg. Three flaps recovered pain sensation with the mean static 2-point discrimination of 13.7 ram, while the remains recovered deep tactile sensation. Mean Disabilities of Armand Shoulder questionnaire score at final follow-up was 12.1 points. All patients could walk within two weeks postoperative. Only one patient felt mild pain at 3 months postoperative. There was no hypertrophicscar or genuine keloid in the donor site at one year postoperative. Conclusion Modified iliac osteocutaneous flap transferring is effective for the treatment of composite defect of metacarpal bone. The morbidity at the donor site is minimal.