手指Ⅳ度烧伤创面的修复方法与临床效果

Repair methods and clinical effects of full-thickness burn wounds deep to tendon or even bone in fingers

目的探讨手指Ⅳ度烧伤创面的修复方法与临床效果。方法采用回顾性非随机对照试验方法。2010年1月—2019年12月,中南大学湘雅医院收治98例符合入选标准的手指Ⅳ度烧伤患者,其中男81例、女17例,年龄1~72岁,共160指受累。患指单指创面面积为2.0 cm×1.5 cm~12.0 cm×3.5 cm,将患指并指后最大创面面积为12.0 cm×10.0 cm。成人手部存在多指多处Ⅳ度烧伤创面时或者儿童手指Ⅳ度烧伤时,选用腹部带蒂皮瓣;成人单指或2指Ⅳ度烧伤时,选用手内带蒂皮瓣与游离组织瓣,其中游离组织瓣修复需受区血管条件好且有可供吻合的动静脉;拇指指甲Ⅳ度烧伤或拇指烧伤后部分缺失时,采用第1趾甲皮瓣或带第2趾的足背皮瓣重建拇指。本组采用45个腹部带蒂皮瓣修复91指创面,37个手内带蒂皮瓣修复37指创面,26个游离组织瓣修复28指创面,3个第1趾甲皮瓣重建3例患者拇指指甲并修复手部创面,1个带第2趾的足背皮瓣重建1例患者拇指并修复手、腕部创面。组织瓣面积为2.0 cm×1.5 cm~20.0 cm×10.0 cm。供瓣区创面直接缝合或者于患肢上臂内侧切取全厚皮片、大腿外侧切取断层皮片移植修复。观察术后组织瓣成活情况、术后并发症、供瓣区外观与功能;对获得随访的患者,于末次随访时,采用中华医学会手外科学会断指再植功能评定试用标准评估患指功能,采用疗效满意度评分表调查患者满意度。对数据行Kruskal-Wallis H检验与Nemenyi法检验。结果112个组织瓣中,104个组织瓣完全成活,血运良好;1个带蒂移植的拇指尺背侧逆行岛状皮瓣、1个带蒂移植的指动脉皮支逆行岛状皮瓣、1个游离移植的股前外侧穿支皮瓣末端少许坏死,经换药、肉芽组织生长后,取大腿外侧断层皮片移植修复;2个游离移植的跗外侧动脉皮瓣及1个带蒂移植的拇指尺背侧逆行岛状皮瓣术后静脉回流障碍,予拆除部分缝线、肝素盐水擦拭伤口后皮瓣成活;1个带蒂移植的改良掌背动脉逆行岛状皮瓣、1个游离移植的腓动脉穿支皮瓣坏死,Ⅱ期分别采用腹部带蒂皮瓣、上臂外侧皮瓣游离移植修复。移植组织瓣术后外形好,不臃肿,质地柔软,弹性好;供瓣区无功能障碍,仅遗留轻微瘢痕。72例患者共117指获得3~24个月门诊或电话随访。末次随访时,腹部带蒂皮瓣、手内带蒂皮瓣、游离组织瓣修复患指功能评定优良率分别为77.3%(51/66)、96.3%(26/27)、95.8%(23/24),其中游离组织瓣、手内带蒂皮瓣修复患指功能均明显优于腹部带蒂皮瓣(P<0.01);游离组织瓣修复患指后患者满意度明显高于腹部带蒂皮瓣(P<0.05)。结论结合手指Ⅳ度烧伤创面具体情况,采用腹部带蒂皮瓣修复成人多指多处Ⅳ度烧伤创面或儿童手指Ⅳ度烧伤创面,采用手内带蒂皮瓣或游离组织瓣修复成人单指或2指Ⅳ度烧伤创面,采用第1趾甲皮瓣或带第2趾的足背皮瓣重建Ⅳ度烧伤拇指,术后组织瓣成活率高、并发症少,其中游离组织瓣与手内带蒂皮瓣修复术后患指功能恢复更好,游离组织瓣修复术后患者满意度最高。

Objective To explore the repair methods and clinical effects of full-thickness burn wounds deep to tendon or even bone in fingers.Methods A retrospective non-randomized controlled trial was conducted on the 98 patients with full-thickness finger burns deep to tendon or even bone who met the inclusion criteria and were hospitalized in Xiangya Hospital of Central South University from January 2010 to December 2019.Among the 98 patients,there were 81 males and 17 females,aged from 1 to 72 years,with 160 fingers involved.The wound area of each of affected fingers ranged from 2.0 cm×1.5 cm to 12.0 cm×3.5 cm,and the maximum wound area after merging the affected fingers was 12.0 cm×10.0 cm.For adult hands with multiple full-thickness burn wounds deep to tendon or even bone in multiple fingers or children with full-thickness finger burns deep to tendon or even bone,pedicled abdominal flaps were selected.For adults with single or two fingers with full-thickness burns deep to tendon or even bone,the pedicled internal hand flaps and free tissue flaps were selected.The free tissue flap repair requires good vascular conditions in the recipient area with arteries and veins available for anastomosis.For thumb nail burns deep to tendon or even bone or partial absence of the thumb after burns,the thumbs were reconstructed with the first toenail flap or dorsal foot flap with the second toe.In this study,45 pedicled abdominal flaps were used to repair the wounds in 91 fingers,37 pedicled internal hand flaps were used to repair the wounds in 37 fingers,26 free tissue flaps were used to repair the wounds in 28 fingers,3 first toenail flaps were used to reconstruct 3 patients'thumb nails and to repair hand wounds,and 1 dorsal foot flap with the second toe was used to reconstruct 1 patient's thumb and to repair hand and wrist wounds.The tissue flap area was from 2.0 cm×1.5 cm to 20.0 cm×10.0 cm.The wound in the donor site was repaired by direct suture or full-thickness skin grafting from the medial upper arm of the affected limb or split-thickness skin grafting from the outer thigh.The postoperative survival of the tissue flap,postoperative complications,and appearance and function of the flap donor site were observed.For the patients who were followed up,their finger functions were evaluated at the last follow-up using the trial criteria for replantation function evaluation of the amputated finger issued by the Hand Surgery Society of the Chinese Medical Association,and the satisfaction of the patients was investigated using the Efficacy Satisfaction Scale.Data were statistically analyzed with Kruskal-Wallis H test and Nemenyi test.Results Of the 112 tissue flaps,104 tissue flaps survived completely and had good blood circulation;1 pedicled thumb dorsal ulnar reverse island flap,1 pedicled finger artery cutaneous branch reverse island flap,and 1 free grafted anterolateral thigh perforator flap were slightly necrotic at the end,which were repaired with outer thigh split-thickness skin graft after dressing change and granulation tissue growth;2 free grafted tarsal external artery flaps and 1 pedicled thumb dorsal ulnar reverse island flap suffered from postoperative venous return obstruction,which survived after partial suture removal and heparin saline cleansing of the wound;1 pedicled modified dorsal metacarpal artery retrograde island flap and 1 free grafted peroneal artery perforator flap were necrotic,which were repaired by a pedicled abdominal flap and a lateral upper arm flap free transplantation respectively in stageⅡ.After transplantation,the tissue flaps had good shape,soft texture,and good elasticity,without bloating.There was no functional disorder in the flap donor site,and only slight scar remained.A total of 117 fingers of the 72 patients received 3-24 months of outpatient or telephone follow-up.At the last follow-up,the excellent and good rates of function evaluation of fingers repaired with pedicled abdominal flap,pedicled internal hand flap,and free tissue flap were respectively 77.3%(51/66),96.3%(26/27),and 95.8%(23/24).The function of fingers repaired with free tissue flap and pedicled internal hand flap was significantly better than that with pedicled abdominal flap(P<0.01).The satisfaction of patients with fingers repaired by free tissue flaps was significantly higher than that by pedicled abdominal flap(P<0.05).Conclusions According to the specific situation of full-thickness burn wounds deep to tendon or even bone in fingers,the pedicled abdominal flap is used to repair the multiple full-thickness burn wounds deep to tendon or even bone in multiple fingers of adult or the full-thickness burn wounds deep to tendon or even bone in fingers of children,the pedicled internal hand flap or free tissue flap is used to repair the full-thickness burn wounds deep to tendon or even bone in single or two fingers of adult patients,and the first toenail flap or the dorsal foot flap with the second toe is used to reconstruct the thumbs with full-thickness burn deep to tendon or even bone,with high postoperative tissue flap survival rate and few complications.The functional recovery of the affected finger is better after repair with free tissue flap and pedicled internal hand flap,and the patients'satisfaction is the highest after free tissue flap repair.