高频彩色多普勒超声辅助下拇指尺侧指背动脉逆行岛状皮瓣修复同指远端皮肤软组织缺损的方法与效果

Methods and effects of high-frequency color Doppler ultrasound assisted reverse island flap of dorsal digital artery of ulnar thumb for repairing skin and soft tissue defects in the distal end of the same finger

目的探讨在高频彩色多普勒超声辅助下采用拇指尺侧指背动脉逆行岛状皮瓣修复同指远端皮肤软组织缺损的方法与效果。方法采用回顾性队列研究方法。2014年3月—2020年1月,潍坊市益都中心医院手足外科收治拇指远端皮肤软组织缺损患者43例,其中男28例、女15例,年龄19~58岁,受伤至手术时间4~10 h,创面缺损面积为1.5 cm×1.0 cm~5.0 cm×3.0 cm。术前采用高频彩色多普勒超声探测明确拇指尺侧指背动脉的类型和走行等情况,以此设计拇指尺侧指背动脉岛状皮瓣逆行转移修复同指远端皮肤软组织缺损,拇指尺侧指背动脉缺如者采用以桡掌侧动脉为蒂的大鱼际逆行岛状皮瓣修复,皮瓣面积为2.0 cm×1.5 cm~5.5 cm×3.5 cm。供瓣区创面直接拉拢缝合或取同侧上臂内侧中厚皮移植覆盖。记录术前高频彩色多普勒超声探测的拇指尺侧指背动脉情况,比较术前探测的拇指尺侧指背动脉类型、走行、分布范围与术中探查结果,术后观察皮瓣成活情况。末次随访时,观察皮瓣供受区外观,依照中华医学会手外科学会上肢部分功能评定试用标准评价拇指功能,依照感觉功能评定标准评价皮瓣移植部位感觉功能。结果术前高频彩色多普勒超声探测显示,2例患者拇指尺侧指背动脉缺如,另41例患者保留有拇指尺侧指背动脉,其中起始于第1掌背动脉并在第1骨间背侧肌表面走行的1型20例;起始于桡动脉深支或拇主要动脉并在第1骨间背侧肌深面走行的2型16例,包含起始点位于第1掌骨基底区域的2a型10例、起始点位于第1掌骨头区域的2b型6例;起始于第1掌背动脉与拇主要动脉在第1掌指关节区域的交汇处的3型5例。拇指尺侧指背动脉起始处血管外径为(1.12±0.31)mm,伴行静脉起始处血管外径为(0.63±0.21)mm。拇指尺侧指背动脉主要集中在第1掌指关节尺侧和鼻烟窝区域。术中所见拇指尺侧指背动脉类型、走行、分布范围和术前高频彩色多普勒超声探测结果一致。术后,43例患者皮瓣均成活。随访6个月~1年,末次随访时供瓣区仅留有线性瘢痕,拇指尺侧指背动脉逆行岛状皮瓣移植处质地及弹性好、无明显色素沉着、外形美观,拇指功能评价中优23例、良17例、可3例,皮瓣移植部位感觉功能达S4级者16例、S3级者22例、S2级者5例。结论拇指尺侧指背动脉逆行岛状皮瓣是修复同指远端特别是指间关节以远皮肤软组织缺损的理想方法之一。术前高频彩色多普勒超声探测能明确拇指尺侧指背动脉类型、分布,以便设计个性化的手术方案,术后供受区外观及拇指功能佳。

Objective To explore the methods and effects of high-frequency color Doppler ultrasound assisted reverse island flap of dorsal digital artery of ulnar thumb for repairing skin and soft tissue defects in the distal end of the same finger.Methods The retrospective cohort study method was applied.From March 2014 to January 2020,43 patients with skin and soft tissue defects in the distal end of thumb were hospitalized in the Department of Hand and Foot Surgery of Yidu Central Hospital of Weifang,including 28 males and 15 females,aged 19-58 years.The time from injury to operation was 4 to 10 hours,and the area of wound defect was 1.5 cm×1.0 cm-5.0 cm×3.0 cm.The type and course of dorsal digital artery of ulnar thumb were detected by high-frequency color Doppler ultrasound before operation,based on which the reverse transfer of the island flap of dorsal digital artery of ulnar thumb was designed to repair the skin and soft tissue defects in the distal end of the same finger.The patients with absence of the dorsal digital artery of ulnar thumb were repaired by the greater fish reverse island flap pedicled with the radial palmar artery.The area of the flap was 2.0 cm×1.5 cm-5.5 cm×3.5 cm.The donor site wound was directly closed by suturing or covered with split-thickness skin graft from the inner side of the upper arm in the same arm.The status of dorsal digital artery of ulnar thumb detected by high frequency color Doppler ultrasound before operation was recorded.The type,course,and distribution of the dorsal digital artery of ulnar thumb detected before operation were compared with those observed during the operation.The survival of the flap was observed after operation.During the last follow-up,the appearance of the donor and recipient area of flaps was observed,the thumb function was evaluated with trial standard for the evaluation of the functions of the upper limbs of the Hand Surgery Society of the Chinese Medical Association,and the sensory function of the area transplanted with flap was evaluated with the sensory function evaluation standard.Results The results of high-frequency color Doppler ultrasound showed that the dorsal digital artery of ulnar thumb was absent in 2 patients,while 41 patients had the dorsal digital artery of ulnar thumb,among which 20 cases were type 1 that started from the first dorsal metacarpal artery and ran on the surface of the first interosseous dorsal muscle;16 cases were type 2 that started from the deep branch of the radial artery or the main artery of thumb and ran in the deep surface of the first interosseous dorsal muscle,including 10 cases of type 2a with the starting point in the basal region of the first metacarpal bone and 6 cases of type 2b with the starting point in the first metacarpal bone region;5 cases were type 3 that started from the confluence of the first dorsal metacarpal artery and the main thumb artery in the region of the first metacarpophalangeal joint.The outer diameter of the vessel at the beginning of the dorsal digital artery of ulnar thumb was(1.12±0.31)mm,and the outer diameter of the vessel at the beginning of the accompany vein was(0.63±0.21)mm.The dorsal digital artery of ulnar thumb was concentrated in the ulnar side of the first metacarpophalangeal joint and snuff box region.The type,course,and distribution range of the dorsal digital artery of ulnar thumb observed during the operation were consistent with the results detected by high-frequency color Doppler ultrasound before operation.After the operation,the flaps survived in 43 patients.The patients were followed up for 6 months to 1 year.During the last follow-up,only linear scars were left in the donor area;there were no obvious pigmentation in the area transplanted with reverse island flap of dorsal digital artery of ulnar thumb,with good texture and elasticity,and beautiful appearance;the thumb function was evaluated as excellent in 23 cases,good in 17 cases,and fair in 3 cases;the sensory function of the area transplanted with flap was evaluated as S4 level in 16 cases,S3 level in 22 cases,and S2 level in 5 cases.Conclusions The reverse island flap of dorsal digital artery of ulnar thumb is one of the ideal methods to repair the skin and soft tissue defect in the distal end of the same finger,especially that beyond the distal interphalangeal joint.Preoperative detection with high-frequency color Doppler ultrasound can identify the type and distribution of dorsal digital artery of ulnar thumb,so as to design a personalized operation plan,resulting in good appearance of the donor and recipient area and thumb function after operation.