两种同指带蒂皮瓣修复拇指指端或指腹创面的比较

Comparison of two types of pedicled homodigital flap in reconstruction of thumb-tip or thumb-pulp defects

目的:比较同指桡侧指掌侧固有动脉(PPDA)背侧皮支皮瓣与同指尺侧指背动脉(DDA)逆行岛状皮瓣修复拇指指端或指腹创面的临床疗效。方法:采用回顾性病例对照研究方法。自2016年1月至2022年8月,唐山市第二医院手外科收治65例拇指指端或指腹创面患者,分别采用桡侧PPDA背侧皮支皮瓣(PPDA背侧皮支组)修复35例(35指)、尺侧DDA逆行岛状皮瓣(DDA组)修复30例(30指)。PPDA背侧皮支组创面及皮瓣面积范围分别为1.9 cm×1.5 cm~2.9 cm×2.4 cm和2.1 cm×1.7 cm~3.1 cm×2.6 cm,DDA组创面及皮瓣面积范围分别为2.0 cm×1.7 cm~2.9 cm×2.5 cm和2.2 cm×1.9 cm~3.2 cm×2.8 cm。两组患者供区创面均直接缝合。术后观察两组患者皮瓣成活及供区切口愈合情况。记录两组患者手术时间及随访时间。患者随访采用门诊复查、电话及微信视频相结合的方式。末次随访时记录两组患者伤指关节主动总活动度(TAM)、虎口角、皮瓣静态TPD、皮瓣及供区外观满意度。患者皮瓣及供区外观满意度参照密歇根大学手部功能问卷(MHQ)评定标准评定。对两组计量资料行独立样本 t检验,计数资料行 χ2检验或Fisher精确检验, P<0.05为差异有统计学意义。 结果:PPDA背侧皮支组皮瓣35例全部一期成活,DDA组4例皮瓣出现水疱经伤口换药愈合,其余26例一期成活。PPDA背侧皮支组皮瓣一期成活率(100%)高于DDA组(87%),差异有统计学意义( P<0.05)。两组供区切口均一期愈合。PPDA背侧皮支组、DDA组患者手术时间及随访时间分别为(59.11±5.42)min、(15.37±3.32)个月和(61.27±5.96)min、(16.17±3.60)个月,两组比较差异均无统计学意义( P>0.05)。末次随访,PPDA背侧皮支组、DDA组患者伤指TAM和虎口角分别为(135.14±10.04)°、(90.29±4.36)°和(132.17±11.04)°、(89.00±4.81)°,两组差异无统计学意义( P>0.05)。PPDA背侧皮支组患者皮瓣静态TPD[(7.11±1.21)mm]、皮瓣外观满意度[(4.69±0.47)分]及供区外观满意度[(4.43±0.50)分],好于DDA组TPD[(8.20±1.47)mm]、皮瓣外观满意度[(4.40±0.50)分]及供区外观满意度[(4.13±0.57)分],两组差异有统计学意义( P<0.05)。 结论:桡侧PPDA背侧皮支皮瓣与尺侧DDA逆行岛状皮瓣均适用于修复拇指指端或指腹创面。相比尺侧DDA逆行岛状皮瓣,桡侧PPDA背侧皮支皮瓣一期成活率更高,皮瓣感觉与外观及供区外观更好。

Objective To compare the clinical effects between the homodigital radial flap of the dorsal cutaneous branch of radial palmar proper digital artery(PPDA)and the homodigital reverse island flap of the ulnar dorsal digital artery(DDA)on reconstruction of defects in thumb-tip or thumb-pulp.Methods The retrospective case-control study method was used.From January 2016 to August 2022,a total of 65 thumb-tip or thumb-pulp defects were treated in the Department of Hand Surgery of the Second Hospital of Tangshan.Thirty-five defects of thumbs were reconstructed with the homodigital radial flap pedicled with dorsal cutaneous branch of radial PPDA(PPDA group)and the other 30 thumbs were treated by the homodigital ulnar reverse island flap pedicled with ulnar DDA(DDA group).Sizes of the wounds and flaps in PPDA group were 1.9 cm×1.5 cm to 2.9 cm×2.4 cm and 2.1 cm×1.7 cm to 3.1 cm×2.6 cm,respectively,and the dimensions of the wounds and flaps in DDA group were 2.0 cm×1.7 cm to 2.9 cm×2.5 cm and 2.2 cm×1.9 cm to 3.2 cm×2.8 cm,respectively.The wounds of donor site in both groups were all directly closed.Survival of the flaps and wound healing of donor sites were observed in both groups.The time of surgery and duration of follow-up of the 2 groups were recorded.Postoperative follow-up included outpatient clinic visits,telephone reviews and WeChat video-clips.At the final follow-up,record of total active motion(TAM)of the injured thumbs,angle of first web of the affected hands,static TPD of the flaps,patient satisfaction of the appearance of flaps and donor sites were taken.According to the Michigan Hand Function Questionnaire(MHQ)evaluation criteria,the patient satisfaction of the appearance of flaps and donor sites were evaluated.The measurement and count data acquired from both groups were compared by independent sample t-test and χ^(2) tests or Fisher's exact test,respectively.P<0.05 was considered statistically significant.Results All 35 flaps in PPDA group and 26 flaps in DDA group survived primarily,except 4 flaps in the DDA group that showed blisters and healed with dressing changes.The primary survival rate of flap in PPDA group(100%)was higher than that of DDA group(87%),and the difference was statistically significant(P<0.05).Donor sites of both groups healed primary.The time of surgery and duration of follow-up in PPDA and DDA groups were 59.11 minutes±5.42 minutes and 15.37 months±3.32 months,and 61.27 minutes±5.96 minutes and 16.17 months±3.60 months,respectively.There was no statistically significant difference between the 2 groups(P>0.05).At the final follow-up,the thumb TAM and angle of thumb web in PPDA and DDA groups were 135.14°±10.04°and 90.29°±4.36°and 132.17°±11.04°and 89.00°±4.81°,respectively.There was no statistically significant differences between the 2 groups(P>0.05).The static TPD,patient satisfaction of the appearance of flaps and donor sites in PPDA group were 7.11 mm±1.21 mm,4.69 point±0.47 point and 4.43 point±0.50 point,which were better than DDA group[8.20 mm±1.47 mm,4.40 point±0.50 point and 4.13 point±0.57 point,respectively]with a statistically significant difference(P<0.05).Conclusion The homodigital radial flap of the dorsal cutaneous branch of radial PPDA and the homodigital ulnar reverse island flap of the ulnar DDA are both suitable for reconstruction of defects in thumb-tip or thumb-pulp.Compared with the homodigital reverse island flap with the DDA,a homodigital radial flap with the dorsal cutaneous branch of PPDA has advantages in higher primary survival rate,better flap sensation and appearance at both of recipient and donor sites.