前臂掌侧游离动脉化静脉皮瓣修复手部皮肤软组织缺损的疗效观察

FOREARM FREE ARTERIALIZED VENOUS FLAP IN REPAIRING SOFT TISSUE DEFECT OF HAND

目的探讨应用前臂掌侧游离动脉化静脉皮瓣修复手部皮肤软组织缺损的疗效。方法 2008年12月-2013年1月,收治49例手部皮肤软组织缺损患者。男39例,女10例;年龄16~52岁,平均34岁。致伤原因:重物压砸伤34例,锐器割伤7例,撕脱伤5例,高温机器压伤3例。损伤部位:示指21例,中指14例,环指10例,小指1例,虎口区、掌背侧3例。受伤至入院时间2~10 h,平均4.5 h。皮肤软组织缺损范围为2.5 cm×1.5 cm^6.0 cm×4.5 cm。46例合并掌、指骨骨折及肌腱、神经等复合组织损伤。急诊手术43例,择期手术6例。采用同侧前臂掌侧游离动脉化静脉皮瓣修复创面,皮瓣内静脉近端分别与手指动、静脉吻合,皮瓣切取范围为3.5 cm×2.5 cm^7.5 cm×5.3 cm。供区直接拉拢缝合。结果术后7例皮瓣成活质量接近于生理性皮瓣;39例皮瓣出现轻、中度肿胀,散在小水疱形成;3例皮瓣出现严重水肿,并发生不同程度坏死。患者均获随访,随访时间6个月~2年,平均13.5个月。皮瓣质地柔软,外观稍臃肿,皮色略深于手部周围正常皮肤。末次随访时,皮瓣两点辨别觉为16~22 mm,平均20 mm。按照中华医学会手外科学会手功能评定标准,获优21例,良21例,可3例,差4例。结论应用前臂掌侧游离动脉化静脉皮瓣修复手部皮肤软组织缺损,具有皮瓣供区广泛,不损伤主要血管,手术操作简便,术后外观满意的优点。

Objective To observe the effectiveness of the forearm free arterialized venous flap in repairing soft tissue defect of the hand. Methods Between December 2008 and January 2013, 49 cases of soft tissue defects of the hand were treated. There were 39 males and 10 females, aged 16-52 years （mean, 34 years）. Defect was caused by crush injury in 34 cases, cutting injury in 7 cases, avulsion injury in 5 cases, and hot crush injury in 3 cases. The locations were index finger in 21 cases, middle finger in 14 cases, ring finger in 10 cases, little finger in 1 case, and the first web space and the dorsal palm in 3 cases. The duration of injury and admission was 2-10 hours （mean, 4.5 hours）. The size of defects ranged from 2.5 cm × 1.5 cm to 6.0 cm × 4.5 cm. Of them, 46 cases had fracture of metacarpal or finger bone and/or injury of tendon and nerve. Emergency operation was performed in 43 cases and selective operation in 6 cases. All defects were repaired by free arterialized venous flap from the ipsilateral forearm, in which the proximal ends of veins were anastomosed to artery and vein of the finger. The flap size ranged from 3.5 cm × 2.5 cm to 7.5 cm × 5.3 cm. The donor site was directly sutured. Results Seven flaps survived which was similar to physiological free flap. Mild or medium swelling and blister were observed in 39 flaps and heavy swelling and partial necrosis occurred in 3 flaps after operation. The patients were followed up 6 months-2 years （mean, 13.5 months）. The flaps had soft texture, slightly bulky appearance, and deeper color than normal skin. At last follow-up, the two-point discrimination was 16-22 mm （mean, 20 mm）. According to the standard for functional evaluation issued by Hand Surgery Association of Chinese Medical Association, the results were excellent in 21 cases, good in 21 cases, fair in 3 cases, and poor in 4 cases. Conclusion It is an ideal method to repair soft tissue defect of the hand to use forearm free arterialized venous flap. It has the advantages of massive area, no major blood vessel needed to be sacrificed, safe and easy operation, and satisfactory appearance.