前足严重损伤修复重建的临床研究

EFFECTIVENESS OF REPAIRING OR RECONSTRUCTING DEFECTS OF FOREFOOT

目的探讨前足严重损伤修复重建的方法及临床疗效。方法 2006年2月-2013年2月,收治57例前足严重损伤患者。男41例,女16例;年龄19~68岁,平均38.9岁。致伤原因:机动车碾压伤28例,重物砸伤17例,机器挤压伤12例。左足25例,右足32例。伤后至入院时间为0.5~75.0 h,平均4.7 h。第1跖骨缺损9例,第5跖骨缺损8例,第1、2跖骨缺损16例,第4、5跖骨缺损11例,多个跖骨及前足缺损13例;骨缺损范围2.5 cm×1.9 cm×1.5 cm^13.3 cm×11.2 cm×2.7 cm。皮肤软组织缺损范围12.4 mm×6.3 cm^27.2 cm×18.7 cm。采用自体髂骨或游离带血管蒂髂骨瓣、腓骨瓣修复骨缺损重建足弓,游离皮瓣或组合组织移植修复创面。皮瓣供区直接缝合或游离植皮修复。结果术后3例皮瓣出现静脉危象,2例皮瓣边缘部分坏死,均经对症处理后愈合。其余皮瓣及供区皮片均顺利成活,创面Ⅰ期愈合。51例患者获随访,随访时间1.5~2.5年,平均2.1年。皮瓣外观满意,术后1.5年皮瓣两点辨别觉为8.4~19.8 mm,平均13.7 mm;按照中华医学会手外科学会上肢部分功能评定试用标准,感觉恢复至S_2 6例,S__3 18例,S_4 27例。患者开始负重时间为术后2~6个月,平均3.9个月;植骨均愈合,愈合时间3~6个月,平均4.2个月。术后1.5年,根据美国矫形足踝协会(AOFAS_)评分,获优19例、良24例、中7例、差1例,优良率达84.3%。结论采用自体髂骨或游离带血管蒂髂骨瓣、腓骨瓣重建足弓,游离皮瓣或组合组织移植修复前足严重毁损伤可获得满意疗效。

Objective To evaluate the effectiveness of repairing or reconstructing defects of the forefoot.Methods Between February 2006 and February 2013,57 patients with defects of the forefoot were treated.There were41 males and 16 females with an average age of 38.9 years（range,19-68 years）.The disease causes included motor vehicles crush injury in 28 cases,crashing injury in 17 cases,and machine extrusion injury in 12 cases.The left side was involved in 25 cases and the right side in 32 cases,with a mean disease duration of 4.7 hours（range,0.5-75.0 hours）.Defect located at the 1st metatarsus in 9 cases,at the 5th metatarsus in 8 cases,at the 1st and the 2nd metatarsus in 16 cases,at the 4th and 5th metatarsus in 11 cases,at multiple metatarsus and the forefoot in 13 cases.The bone defect ranged from2.5 cm×1.9 cm×1.4 cm to 13.3 cm×11.2 cm×2.7 cm.The soft tissue defect ranged from 12.4 cm×6.3 cm to 27.2 cm×18.7 cm.The iliac bone or vascularized iliac bone or vascularized fibula bone was used to rebuild the arch of the foot,and free flap was used to repair defects of the forefoot.The donor site was sutured directly or covered with skin graft.Results Venous crisis and partial necrosis occurred in 3 and 2 flaps respectively,which healed after symptomatic treatment.The other flaps and grafted skins survived,and wounds healed primarily.Fifty-one cases were followed up 1.5-2.5 years（mean,2.1 years）.The appearance was excellent and the feeling of the flap recovered at different levels.The two-point discrimination was 8.4-19.8 mm（mean,13.7 mm） at 1.5 years after operation.According to upper extremity functional evaluation standard by hand surgery branch of Chinese Medical Association,sensation recovered to S__2 in 6 cases,to S__3 in 18 cases,and to S__4 in 27 cases.The patients began to walk with weight loading at 2-6 months after operation（mean,3.9 months）.The bone healing time was 3-6 months（mean,4.2 months）.Based on American Orthopaedic Foot and Ankle S_ociety（AOFAS_） standards,the results were excellent in 19 cases,good in 24 cases,fair in 7 case,and poor in 1 case,and the excellent and good rate was 84.3%.Conclusion It is a good solution to treat defects of the forefoot to use iliac bone or vascularized iliac bone or vascularized fibula bone for rebuilding the arch of the foot and use free flap for repairing defect.