足部一蒂双瓣联合植骨修复儿童拇指末节缺损

Repair of thumb paratelum defects using two flaps based on one pedicle from the same foot combined with bone graft in children

目的应用同蒂躅甲皮瓣、第二趾胫侧皮瓣瓦合并髂骨植骨修复儿童拇指末节缺损的手术方法及临床疗效。方法2008年3月至2012年4月收治拇指末节缺损的患儿10例，男6例6指（右侧4例，左侧2例），女4例（右侧2例，左侧2例）。年龄8415岁，平均11岁。10例均于末节基底部以远缺损，其中5例于甲根部平面以远缺损，4例于甲根部平面与指间关节平面的中部以远缺损，1例于甲床近1／4以远缺损；指间关节及远节指骨骨骺均完好。皮肤软组织缺损面积1．6cm×1．3cm～2．5cm×2．0cm，指骨缺损长度0．9～2．0cm。全部病例均为择期修复，采用游离同蒂躅甲皮瓣、第二趾胫侧皮瓣瓦合并髂骨植骨进行修复，足部供区采用腹部全厚皮片植皮。结果术后10例移植的组织全部成活，伤口均一期愈合，足部供区植皮均顺利成活。术后随访12～36个月，平均18个月，拇指末节功能外形均满意，指甲生长良好，末节指骨均达到骨性愈合。按中华医学会手外科学会拇、手指再造功能评定试用标准评定，优9例，良1例。供足活动无明显影响。结论应用同蒂躅甲皮瓣、第二趾胫侧皮瓣瓦合并髂骨植骨修复儿童拇指末节缺损是一种较好的临床方法，功能外形恢复满意。

Objective To report the operative technique and clinical outcomes of dorsal nail-skin flap from the big toe and tibial flap from the second toe based on one pedicle combined with ilium graft for repairing of thumb paratelum defects in children. Methods From March 2008 to April 2012, 10 patients with tissue defects of the thumb paratelum were treated. There were six males （four with right-sided defects,two with left） and four females （two with right, two with left） with age ranging from 8 to 15 years （average, 11 years）. The defect level of all cases was from fingertip to the base of distal phalanx of the thumb,including the root of the nail in five cases, the middle of the nail and the interphalangeal joint in four, and a quarter of the nail in one. Both interphalangeal joints and epiphyses of the distal phalanx of the thumb were normal. The sizes of the soft tissue defects varied from 1.6 cm × 1.3 cm to 2. 5 cm × 2.0 cm. The lengths of the phalanx defects ranged from 0. 9 cm to 2. 0 cm. All cases underwent selective reconstruction with dorsal nail-skin flap from the big toe and tibial flap from the second toe based on one pedicle combined with ilium graft. The donor sites of the big toe and the second toe were covered by abdominal full thickness skin graft. Results All 10 combined flaps survived. The wound healed primarily. Skin grafts in the donor sites also survived. Postoperative follow-up ranged from 12 to 36 months, with an average of 18 months. The function and appearance of the thumb paratelum were satisfying. Thumb nail grew well. Distal phalanx healed firmly. According to the criteria issued by the Hand Surgery Society of Chinese Medical Association for functional assessment of reconstucted thumb and fingers,9 were graded as excellent and 1 as good. There was no apparent influence on the foot function. Conclusions Combined dorsal nail-skin flap from the big toe and tibial flap from the second toe based on one pedicle with bone graft is a good method for repairing the defects of thumb paratelum in children with good appearance and satisfactory functional results.