桡侧副动脉嵌合穿支皮瓣修复拇指复合组织缺损

Radial collateral artery perforator flap combining a vascularized fragment of the distal humerus in reconstruction of thumb complex defects

目的探讨携带肱骨瓣的桡侧副动脉嵌合穿支皮瓣移植修复拇指复合组织缺损的可行性与临床疗效.方法本组5例拇指复合组织缺损病例,均为2014年6月至2018年10月就诊于中南大学湘雅医院的男性患者,年龄35~63岁,平均47岁.右拇指2例,左拇指3例.皮肤缺损面积为16.0 cm×4.0 cm^3.5 cm×2.0 cm,骨缺损长度为2 cm^3 cm.彻底清创后采用桡侧副动脉嵌合穿支皮瓣游离移植修复,皮瓣切取面积为18 cm×5 cm^4 cm×2 cm,骨瓣为2.5 cm×1.0 cm×0.5 cm^2.0 cm×0.6 cm×0.5 cm,皮瓣均携带臂后侧皮神经,术中行显微削薄2例,用克氏针将骨瓣与指骨或掌骨固定后将桡侧副血管与鼻咽窝处的桡动脉、头静脉吻合,所有供区均直接闭合.结果术后5例皮瓣完全成活、无感染,创面一期愈合,术后4~6周去除克氏针.随访3个月至4.5年,移植骨瓣均骨性愈合,拇指对掌、对指功能良好.手部功能评定:优3例,良2例;感觉恢复至S4级1例、S3级3例、S2级1例.患指外观满意度评价:3例为5分,2例为4分.结论桡侧副动脉嵌合穿支皮瓣可同时进行皮肤软组织与骨组织重建,术后拇指感觉、功能恢复良好,外观满意,是一种修复拇指复合组织缺损的有效方法.

Objective To explore the efficiency and effect of radial collateral artery chimeric perforator flap combining a vascularized fragment of the distal humerus to reconstruct thumb complex defects. Methods 5 cases of thumb complex tissue defects patients admitted to Xiangya Hospital of Central South University from June 2014 to October 2018. The patients were all male and aged from 35 to 63 years ( average age was 47 years). There were 2 cases of right thumb and 3 cases of left thumb. The skin defect area was from 16. 0 cm×4. 0 cm to 3. 5 cm×2. 0 cm, and the bone defect length was 2-3 cm.All defects were reconstructed with radial collateral artery chimeric perforator flap combining a vascularized fragment of the distal humerus. The sizes of perforator flap were from 4 cm×2 cm to 18 cm×5 cm, and the sizes of bone were from 2. 0 cm × 0. 6 cm × 0. 5 cm to 2. 5 cm × 1. 0 cm × 0. 5 cm. The posterior branchial cutaneous of the arm was included in skin flap. 2 flaps underlied microdissect to defat. After fixing bone flap and finger/metacarpal bone with Kirschner wires,the radial accessory vessels were anastomosed with the radial vessels and cephalic vein at the nasopharyngeal fossa.All donor sites were closed directly. Results All flaps survived uneventfully. Kirschner wires were removed 4 to 6 weeks after operation. Postoperative follow-up ranged from 3 months to 4. 5 years (average 19 months). All bone flaps healed without union. Functions of thumb opposition and thumb to finger were all good. The hand function had excellent result in 3 cases and good in 2 cases. Sensory recovered to S4 in 1 case, S3 in 3 cases and S2 in 1 case. Evaluation of the appearance satisfaction of patients was 5 points in 3 cases and 4 points in 2 cases. Conclusions The radial collateral artery chimeric perforator flap combining a vascularized fragment of the distal humerus, which can reconstruct skin soft tissue and bone simultaneously, has good postoperative feeling and function recovery, and satisfactory appearance, and is an effective method to repair the defect of thumb complex tissue.