拇趾甲皮瓣及尺动脉腕上皮支下行支皮瓣瓦合并髂骨植骨再造拇指末节缺损

Clinical study on reconstruction of distal thumb defect using wrap-around flap from the big toe, free flap based on the descending branch of ulnar artery above-wrist cutaneous branch and iliac crest bone graft

目的探讨拇趾甲皮瓣及尺动脉腕上皮支下行支皮瓣瓦合并髂骨植骨再造拇指末节缺损的临床疗效。方法对7例拇指末节缺损患者分别采用吻合血管拇趾甲皮瓣修复拇指背侧皮肤及指甲缺损、尺动脉腕上皮支下行支皮瓣修复拇指末节掌侧皮肤缺损、末节指骨缺损取髂骨移植。拇趾甲皮瓣供区采用游离植皮5例,同侧第2趾胫侧方皮瓣顺行覆盖2例;尺动脉腕上皮支下行支皮瓣供区均直接缝合。结果 7例拇趾甲皮瓣及尺动脉腕上皮支下行支皮瓣均顺利成活,伤口一期愈合。其中1例拇趾甲皮瓣供区植皮出现部分坏死,经换药后愈合。末节植骨愈合时间为8~11周,平均10周。去除内固定物后行规律功能锻炼。所有患者获随访6~15个月,平均8个月,移植组织成活及拇指指甲生长良好,指腹皮瓣两点辨别觉为8~10 mm(平均9 mm);足部供区皮瓣及植皮无破溃,足部功能未受影响。结论采用拇趾甲皮瓣及尺动脉腕上皮支下行支皮瓣瓦合并髂骨植骨再造拇指末节能较好地恢复拇指外形及功能,是一种较好的临床治疗方法。

Objective To explore the clinical efficacy of wrap-around flap from the big toe combined with free flap based on the descending branch of ulnar artery above-wrist cutaneous branch and iliac bone graft in the reconstruction of distal thumb defect. Methods For 7 patients with distal thumb defects, the wrap-around flap from the big toe was used to repair dorsal thumb skin and nail defects,the free flap based on the descending branch of ulnar artery above-wrist cutaneous branch was used to repair palm volar skin defects of distal thumb, and iliac crest bone graft was used to repair distal phalanx defects. The donor site of the hallux toenail flap was covered by free skin graft in 5 patients and covered by ipsilateral tibial skin flap of the second toe in 2 patients. The donor sites of free flap based on the descending branch of ulnar artery above-wrist cutaneous branch were directly sutured. Results All flaps in 7 patients were survived and the wounds were healing by first intention. Partial necrosis occurred in skin graft of donor site of hallux toenail flap in 1 patient and healed after dressing change. The healing duration of distal phalanx was from 8 to 11 weeks, with an average of 10 weeks. Regular functional exercise was performed after internal fixation was removed. All patients were followed-up from 6 to 15 months, with an average of 8 months.The transplanted tissue survived well and the nail of thumb grew well. The two-point discrimination of finger pulp flap was 8 to 10 mm,with an average of 9 mm. There was no ulceration in the skin flap and skin graft of donor site. The function of foot was not affected. Conclusion The application of wrap-around flap from the big toe combined with free flap based on the descending branch of ulnar artery above-wrist cutaneous branch and iliac crest bone graft was an ideal clinical method for reconstruction of distal thumb defect. This method could restore the appearance and function of thumb.