重度拇指发育不良的示指拇化手术效果初步分析

Outcome analysis after index pollicization for severe congenital thumb hypoplasia

目的探讨示指拇化手术治疗重度拇指发育不良的功能与外观效果。方法2010年6月至2018年11月间对在北京积水潭医院手外科就诊的26例Manske改良BlauthⅢB~Ⅴ型拇指发育不良患儿进行示指拇化手术治疗。患儿手术时平均月龄为37个月(15~89个月),男19例,女7例,左手8例,右手15例,双手3例,ⅢB型4只手,Ⅳ型16只,Ⅴ型9只。术后随访外观及功能,测量拇指外展角度、Kapandji评分、捏力、指间关节和掌指关节的活动度。检查腕掌关节稳定性。使用Goldfarb功能评分和Likert量表评分评价拇指的总体功能。观察X线片上新拇指掌骨近端骨骺是否闭合,有无手术并发症。对患儿监护人和随访医生进行主观拇指外形及功能满意度调查。分析监护人对外形及功能满意度与客观指标之间的相关性、监护人与医生满意度之间的差异、3岁前与3岁后手术满意度之间的差异。结果26例患儿平均随访42个月,平均拇指桡侧外展46.2°,掌侧外展34.1°,平均Kapandji评分7.1分。平均指间关节伸直3.4°,屈曲40.7°,掌指关节伸直4.1°,屈曲38.6°。捏力(侧捏、对捏、三指捏)平均值分别为0.5、0.8、1.2 kg。所有腕掌关节稳定。Goldfarb评分平均为4分。Likert量表平均为22分。所有骨骺没有闭合。6例虎口皮肤浅表坏死,1例虎口轻度挛缩。患儿监护人对拇指外形及功能的满意度与各个客观指标之间没有相关性。患儿监护人对拇指外形及功能满意度显著低于医生满意度。监护人和医生满意度在3岁之前和3岁之后手术之间差异无统计学意义。结论对Manske改良BlauthⅢB~Ⅴ型拇指发育不良患儿行示指拇化手术,术后功能满意,但存在拇指对掌和屈指力弱的问题。医生的主观满意度较高,监护人的主观满意度较低。

Objective This study aimed to investigate the functional and aesthetical outcomes after index pollicization for severe congenital thumb hypoplasia.Methods From June 2010 to November 2018,26 patients(29 hands)with Manske modified Blauth typeⅢB-V thumb hypoplasia who were admitted to Department of Hand Surgery,Beijing Ji Shui Tan Hospital were treated with index pollicization.Thumb abduction angles,Kapandji score,pinch forces,interphalangeal and metacarpophalangeal ranges of motion were measured.The stability of carpometacarpal joint was checked.Goldfarb function score and Likert scale score were used to evaluate overall function of thumb.Whether new first metacarpal’s physeal closure presence was observed on X-ray film.Postoperative complications were recorded.The patients’guardian’s and follow-up doctor’s subjective satisfactions on thumb appearance and function were surveyed.The correlation between guardian’s satisfaction and objective indicators,the differences between guardian’s and doctor’s satisfactions,the difference between operation satisfaction before and after 3 years old were analyzed.Results Among 26 patients(4 typeⅢB,16 typeⅣ,and 9 type V),there were 19 males and 7 females with an average age of 37 months(range:15-89 months)during surgery,including 8 left hands,15 right hands and 3 bilateral hands.The average follow-up was 42 months.Average thumb radial abduction was 46.2°,average palmar abduction was 34.1°,and average Kapandji score was 7.1.Average angle of interphalangeal joint extension was 3.4°,flexion 40.7°,metacarpophalangeal joint extension 4.1°,flexion 38.6°.The average pinching forces(key pinch,tip pinch and tripod pinch)were 0.5 kg,0.8 kg and 1.2 kg respectively.All carpometacarpal joints were stable.The average Goldfarb score was 4.The average Likert scale was 22.All epiphyses were open.First web contracture and superficial skin necrosis were respectively observed in 1 and 6 cases.There was no correlation between the guardian’s satisfaction and the objective indicators.The guardian’s satisfaction on thumb appearance and function was significantly lower than that of doctors’.There was no significant difference in guardian’s and physician’s satisfaction between patients before and after 3 years old.Conclusions Satisfactory functional outcomes can be obtained after index pollicization for patients with Manske modified BlauthⅢB-V thumb hypoplasia,with weak strength of thumb opposition and flexion.The subjective satisfaction of doctors was higher and that of guardians was lower.