改良拇指桡背侧皮神经营养血管皮瓣在拇指缺损重建中的应用

Thumb defect reconstruction with a large dorsal radius neurocutaneous vascular flap of thumb

目的探讨改良拇指桡背侧皮神经营养血管皮瓣在拇指缺损重建的手术方法和临床效果。方法回顾性分析2019年4月—2022年8月中国人民解放军联勤保障部队第九八七医院烧伤整形显微外科收治拇指末节离断伤无法再植或者再植失败患者7例,男性6例,女性1例;年龄20~51岁,平均39.4岁;左手4例,右手3例;挤轧伤5例,切割伤2例;因指体毁损严重无法再植4例,再植失败后行皮瓣修复3例。剔除离断指体近端的坏死组织后保留指骨,采用、改良大面积拇指桡背侧皮神经营养血管皮瓣包裹外露指骨重建拇指末节,供区行植皮覆盖。出院后随访皮瓣外观、感觉,以及供区和手功能恢复情况。结果患者缺损面积为2.5 cm×4.5 cm~3.0 cm×6.0 cm,皮瓣切取面积为2.5 cm×5.0 cm~3.5 cm×6.5 cm。7例皮瓣全部存活,供区植皮全部成活。术后随访3~20个月,平均4.6个月。术后3个月,皮瓣外形饱满,无臃肿,质地满意,感觉初步建立。根据中华医学会手外科分会上肢部分功能评定试用标准评价手指功能:优5例,良1例,可1例,差1例,优良率85.7%。结论经改良后进一步将拇指桡背侧皮神经营养血管皮瓣切取面积扩大,包裹外露指骨重建拇指末节,皮瓣血运可靠,手术操作简便、成功率高,供区损伤小,临床效果满意,值得推广。

Objective To explore the surgical method and clinical effect of wrapping the exposed phalanx with a large dorsal radius neurocutaneous vascular flap of the thumb to reconstruct the distal segment of the thumb.Methods From Apr.2019 to Aug.2022,7 patients with amputated distal segments of the thumb that cannot be replanted or failed in replantation due to severe tissue damage were hospitalized in the NO.987 Hospital of the PLA Joint Logistics Support Force.There were 6 males and 1 female aged 20-51 years,mean 39.4 years.There were 5 cases of squeezing injury and 2 cases of cutting injury with 4 on the left and 3 on the right.Four cases were unable to be replanted due to severe finger damage,and 3 cases underwent skin flap repair after failed replantation.After removing necrotic soft tissue on the proximal severed finger,the phalanx was preserved,and a large dorsal radius neurocutaneous vascular flap of the thumb was used to wrap the exposed phalanx to reconstruct the distal phalanx.The donor site was then covered by grafts.The appearance and sensation of the flap,donor site condition,and hand functional recovery were followed up after discharge.Results The size of the defect area was 2.5 cm×4.5 cm to 3.0 cm×6.0 cm,while the flap was slightly larger,with the size being 2.5 cm×5.0 cm to 3.5 cm×6.5 cm.All the 7 large flaps and the donor site grafts survived.Patients were followed up for 3-20 months,mean 4.6 months.After 3 months of surgery,the skin flap showed a plump appearance,no bloating,and a satisfactory texture.The sensation was initially established.According to the tentative criteria for upper limb function evaluation by the Society of Hand Surgery,Chinese Medical Association,the finger function was evaluated as excellent in 5 cases,good in 1,fair in 1 and poor in 1,with an excellent-to-good rate of 85.7%.Conclusion Reconstruction of the distal segment of the thumb by wrapping the exposed phalanx with a large dorsal radius neurocutaneous vascular flap of the thumb is a simple and successful surgical procedure with minimal invasion to the donor site and satisfactory clinical outcomes.It is worthy of promotion in grassroots hospitals.