3D打印技术辅助设计游离皮瓣修复虎口挛缩松解术后软组织缺损

3D printing assisted design of free flap for reconstruction of the soft tissue defect after release of contracture of the first web space

目的探讨应用3D打印技术辅助设计游离皮瓣修复虎口挛缩松解术后软组织缺损的临床疗效。方法2018年3月至2023年6月,苏州瑞华骨科医院手外科收治10例虎口挛缩患者,其中男6例,女4例,平均年龄34.4(16~52)岁。损伤原因:重物碾压伤6例,机器绞伤3例,滚筒挤压伤1例。虎口角为(20.5±4.5)°,虎口宽度为(2.2±0.2)cm。术前通过手持3D扫描仪获得健侧虎口的三维立体图像,应用Mimics软件虚拟手术辅助设计系统的镜像技术和体表标志切口线,先于患侧画出实际切口线,根据体表标记于健侧画出对应的切口线,扫描健侧后再镜像出患侧虎口开大后的图像,再3D打印出模型。皮瓣宽度小于4.0 cm(6例)采用小腿穿支皮瓣修复,其中腓浅动脉穿支皮瓣5例,腓肠内侧动脉穿支皮瓣1例;宽度大于4.0 cm(4例)采用股前外侧穿支皮瓣(ALTPF)修复。切取皮瓣的面积3.7 cm×2.5 cm~16.0 cm×9.0 cm,皮瓣供区均直接缝合。术后采用医用高分子夹板固定拇指于外展、对掌位2周,并定期来院门诊随访,观察皮瓣的成活情况和拇指的感觉、功能恢复情况。结果术中10例皮瓣均按术前设计切取,切取顺利,切取的皮瓣符合虎口创面。术后10例皮瓣均顺利成活,外形满意,术后随访5~24个月,平均11个月,患侧虎口外形明显改善,2例皮瓣恢复保护性感觉,其余8例皮瓣TPD为8~14 mm,虎口角为(85.2±3.5)°,虎口宽度为(5.8±0.6)cm,拇对掌、对指及内收、外展活动良好,皮瓣供区瘢痕轻微。结论应用3D打印技术可准确设计皮瓣修复虎口挛缩松解术后软组织缺损创面,个性化选择合适的游离皮瓣,能恢复良好的虎口外形及功能。

Objective To investigate the clinical effectiveness of 3D printing assisted design of free flap for reconstruction of the soft tissue defect after release of contracture of the first web space.Methods Ten patients with the first web space contracture were treated in Department of Hand Surgery of Suzhou Ruihua Orthopaedic Hospital from March 2018 to June 2023.The patients were 6 males and 4 females,aged 16-52 years old with an average age of 34.4 years old.The causes of injury were:6 of heavy object crush,3 of machine strangulation and 1 of roller crush.On admission,the average angle and width of the first web space were found at 20.5°±4.5°and 2.2 cm±0.2 cm,respectively.Before surgery,3D images of the healthy first web space was acquired by handheld 3D scanner.The actual incision line on the affected side was manually drawn first,then a corresponding incision line was drawn on the healthy side according to the marking on the affected side.After having the healthy side 3D scanned,a virtual 3D image was mirrored to the affected side with fully opened first web space in the 3D software,and finally the template of a fully opened first web space of the affected side was 3D printed.Then 3D templates of the corresponding flaps were created by 3D printing.A perforator flap from calf was harvested for a flap designed less than 4.0 cm in width,including 5 perforator flaps of superficial peroneal artery and 1 perforator flap of medial sural artery.Anterolateral thigh perforator flaps(ALTPF)were used in 4 patients due to the width was greater than 4.0 cm.The sizes of flaps were 3.7 cm×2.5 cm to 16.0 cm×9.0 cm.All flap donor sites were sutured directly.After surgery,thumbs were fixed with a medical polymer splint in the abduction and palmar opposite position for 2 weeks.Patients were included in postoperative follow-up regularly at outpatient clinic to observe the survival of the flap and the recovery of sensation and function of the thumb.Results Flaps were harvested according to the preoperative designs and the wounds of the first web space were covered by the specifically and individually designed flaps.All flaps survived without any incidence and all with satisfactory final appearances.The appearances of all the first web spaces were significantly improved at 5 to 24 months(11 months in average)after surgery.The protective sensation was regained in 2 patients.Of the rest of 8 patients,the average TPD of the flaps was found at 8-14 mm,with a mean angle of the first web space of 85.2°±3.5°and the average width of the first web space of 5.8 cm±0.6 cm.Thumb to palm and to finger oppositions and thumb adductions and abductions were all good.Scars at the donor sites were minimal.Conclusion The 3D printing can be applied in accurate design of the flap in therefore the soft tissue defect after releace of contracture of the first web space.It allows an individual design of suitable free flap,therefore leads to the restoration of both appearance and function of the first web space.