拇指组合再造的应用解剖

Applied anatomy of combined thumb reconstruction

目的为游离趾甲瓣组合第二趾骨关节肌腱复合组织瓣再造拇指提供更加贴近临床应用的解剖学依据。方法对12侧红色乳胶灌注的成人踝关节以下新鲜足部标本行显微解剖,观测FDMA(第一跖背动脉)、FPMA(第一跖底动脉)的走行、吻合、分支特点,观察甲瓣、第二趾骨关节肌腱复合组织瓣的血供特点。模拟切取趾甲瓣组合第二趾骨关节肌腱复合组织瓣组合再造拇指,观察其外观、血管蒂情况。结果12侧标本中FDMA与FPMA的吻合类型:Ⅰ型41.6%,Ⅱ型25.0%,Ⅲ型16.7%,Ⅳ型16.7%,Ⅴ型本组未发现。FDMA的Gilbert分型:Ⅰ型25.0%,Ⅱ型66.7%,Ⅲ型8.3%。趾甲瓣内血供主要来源为FDMA或FPMA发出的趾趾背动脉、趾腓侧趾底动脉。第二趾复合组织瓣的供血来源主要为第二趾趾背动脉、第二趾胫侧趾底动脉。二者静脉系统为趾、第二趾趾背静脉-第一趾背静脉-大隐静脉。趾甲瓣与第二趾骨关节肌腱复合组织瓣组合后,再造拇指外形美观,血管蒂存在扭转但无卡压,携带胫侧菱形皮瓣后供区仍可一期缝合。结论正确选择趾甲瓣、第二趾复合组织瓣的供血系统及处理血管蒂部,可为趾甲瓣组合第二趾骨关节肌腱复合组织瓣再造拇指提供充足的血供,且再造拇指外形接近正常拇指,具备恢复较好活动功能的条件。

Objective To provide anatomical basis closer to clinical application for the reconstruction of thumb with free toenail flap combined with compound tissue flap of joint and tendon of the second toe.Methods The microanatomy was performed on 12 fresh foot specimens perfused with red latex.The characteristics of the first dorsal metatarsal artery(FDMA)and the first plantar metatarsal artery(FPMA)in course,anastomosis and branches were observed,and the blood supply of toenail flap and the compound tissue flap of joint and tendon of the second toe was observed.The thumb was reconstructed by cutting the toenail flap combined with compound tissue flap of joint and tendon of the second toe,and the appearance and vascular pedicle of the thumb were observed.Results The types of FDMA and FPMA were 41.6%in typeⅠ,25.0%in typeⅡ,16.7%in typeⅢ,16.7%in typeⅣ,and no typeⅤwas found in this group.The Gilbert classification of FDMA was 25.0%in typeⅠ,66.7%in typeⅡ,8.3%in typeⅢ.The main blood supply of toenail flap was from the dorsal toenail artery and the fibular plantar toenail artery of FDMA or FPMA.The blood supply of the second toe composite flap was mainly from the dorsal digital artery of the second toe and the tibial plantar digital artery of the second toe.The two vein systems were the dorsal vein of the big toe and the second toe,the first dorsal vein of the second toe and the great saphenous vein.After the combination of toenail flap and compound tissue flap of joint and tendon of the second toe,the shape of reconstructed thumb was beautiful,and the vascular pedicle had torsion but no compression.The donor area could still be sutured in one stage with the tibial rhomboid flap.Conclusion The proper selection of the blood supply system and treatment of the vascular pedicle of the toenail flap and the second toe composite tissue flap can provide sufficient blood supply for the thumb reconstruction with the toenail flap combined with compound tissue flap of joint and tendon of the second toe,and the shape of the reconstructed thumb is close to the normal thumb,so it has the conditions to restore good activity.