含部分髂胫束的股前外侧皮瓣移植修复手和腕背复合组织缺损

Transfer of anteriolateral thigh flap with partial iliotibial tract in reconstruction of composite tissue defect in dorsal wrist and hand

目的探讨应用含部分髂胫束的股前外侧皮瓣(ALTF)移植修复手和腕背复合组织缺损的疗效。方法2018年3月-2022年8月,永康市骨科医院手外科收治10例手和腕背部大面积复合组织缺损患者,年龄24~48(平均37)岁。10例均伴有3指或以上伸指肌腱缺损,各指肌腱缺损长5.0~11.0 cm,共35指,软组织缺损范围6.0 cm×8.0 cm~11.0 cm×21.0 cm。6例合并掌、指骨骨折缺损和掌指关节囊缺损。均予以急诊彻底清创,对合并的骨折予以内固定后VSD敷料覆盖。3~5 d后采用含部分髂胫束的ALTF移植修复手和腕背软组织缺损,皮瓣切取范围6.0 cm×9.0 cm~9.0 cm×17.0 cm,剩余创面植皮覆盖,并同期重建伸指功能。供区9例直接拉拢缝合,1例取腹部皮片植皮。术后采用门诊、电话或微信随访,包括皮瓣感觉、外观及供区愈合情况,手部伸指功能恢复情况按总主动活动度(TAM)系统评定方法进行评定。结果除1例皮瓣术后出现血管危象,经2次手术探查并行血管移植后皮瓣成活外,其余皮瓣均顺利成活。随访6~24个月,平均13个月。末次随访时皮瓣质地柔软,外观轻度臃肿,无明显色素沉着,感觉恢复S27例、S33例,均无伸肌腱再次断裂,手功能按TAM系统评定:优3指,良18指,可9指,差5指;供区留线形瘢痕。结论含部分髂胫束的ALTF移植修复手和腕背复合组织缺损,在修复创面的同时,可重建伸指功能。

Objective To investigate the curative effect of transfer of free anteriolateral thigh flap(ALTF)with partial iliotibial tract on reconstruction of composite tissue defects in dorsal wrist/hand.Methods Ten patients who were admitted in the Department of Hand Surgery of Yongkang Orthopaedic Hospital from March 2018 to August 2022 were entered in the study due to extensive composite tissue defects in dorsal wrists and hands.The patients were 24-48(37 in average)years old.All patients had tendon defects in 3 or more digits with 35 digits in total.The length of the tendon defects were 5.0-11.0 cm in various digits.The soft tissue defects ranged from 6.0 cm×8.0 cm to 11.0 cm×21.0 cm in size.Six patients had defects accompanied with metacarpal and phalangeal bone fracture and joint capsule.In emergency surgery,all patients received thorough debridement and VSD coverage after internal fixation for combined fractures.At 3-5 days after the primary surgery,free ALTF transfer with partial iliotibial tract was employed to reconstruct the defects on dorsal wrists and hands and the digit extension function.The size of flap was 6.0 cm×9.0 cm-9.0 cm×17.0 cm,and the rest of defect wound was covered by skin graft.All the donor sites were sutured directly,except 1 that received abdominal skin graft.Patients had the follow-ups in outpatient clinics,or via telephone or Wechat,to observe the sensation and appearance of the flap,and the healing of the donor site.The recovery of the extension function of the hand was evaluated according to the totle active motion(TAM)system.Results All flaps survived except one that had vascular compromise after the surgery and it survived after two explorations and a vascular transfer.Postoperative follow-ups lasted for 6 to 24 months,with 13 months in average.At the last follow-up,a all the flaps were found soft in texture and slightly swollen in appearance.There was no obvious pigmentation or rupture of skin and extensor tendon.Sensory recovery achieved to S2 in 7 patients and S3 in 3 patients.The hand function was evaluated according to TAM system and rated as excellent for 3 digits,good for 18 digits,fair for 9 digits and poor for 5 digits.There were linear scars in the donor sites.Conclusion Free ALTF transfer with partial iliotibial tract in the reconstruction of composite tissue defect of dorsal wrists and hands can not only reconstruct the wound surface,but also the extension of digits,which cuts short the course of treatment.