综合策略缩容术一次塑形儿童多足趾巨趾畸形的初期效果

Initial clinical outcomes of the comprehensive debulking surgery for one-stage reconstruction of multiple toes macrodactyly in children

目的探讨采用以足趾及足底健侧缘皮瓣为核心的综合策略缩容术一次塑形儿童多足趾巨趾畸形的初期临床应用效果。方法回顾性分析2022年1月至2023年10月重庆医科大学附属儿童医院烧伤整形科手术治疗的多足趾巨趾畸形患儿的临床资料。术中设计以足趾及足底健侧缘为蒂的带部分血管皮穿支的随意型皮瓣,切除超过正常足趾及足底长度以远的组织。严重增长的巨趾切取带一侧趾固有动脉的趾甲复合组织瓣,后退成形趾甲。切除跖腱膜表面、纵行纤维分隔内的增生脂肪以及部分病变神经。趾骨横向截骨缩短、纵向截骨缩窄但不做骨骺阻滞,并进行关节复位成形以及屈肌腱紧缩。最后以足趾健侧缘皮瓣包裹足趾并成形趾蹼,足底健侧缘皮瓣成形足底。记录手术时长、伤口和骨骼愈合时间、足趾和趾甲保留情况。术后随访双足最大周径及鞋码差异、足部皮肤是否有溃疡、伤口瘢痕、趾蹼深度、基本感觉是否存在以及家长的满意度。采用改良巨趾调查问卷评价手术效果,总分0~12分,评分越高说明手术效果越佳。采用描述性方法进行统计分析,符合正态分布的计量资料以±s表示。结果共纳入15例患儿,男11例,女4例,手术时中位年龄为2.75岁(0.9~10.8岁);2趾巨趾11例,3趾巨趾4例,共34趾。手术时长平均为4.13 h(2趾巨趾患儿3.25 h,3趾巨趾患儿5.00 h),1例严重的3趾巨趾行1个趾列切除,2个足趾术中甲瓣切取失败。术后3个足趾趾端部分皮肤坏死,2个甲瓣坏死,经换药后愈合,其余足趾均愈合良好。术后平均随访4.8个月(3~11个月),患侧足与健侧足周径差异均≤1.5 cm,长度差异<0.5 cm,均能穿同码鞋。共4个足趾无趾甲,1个趾甲薄。除1例趾蹼深度不足外,其余趾蹼深度接近正常。足部皮肤无溃疡,基本感觉存在,伤口瘢痕隐蔽。术后改良巨趾调查问卷评分为(10.54±0.88)分,所有家长对效果满意。结论以足趾及足底健侧缘皮瓣为核心的综合策略缩容术修复儿童多足趾巨趾畸形,一次手术可完全切除跖底远端以及趾端的膨大组织,很大程度缩小足及足趾的大小至穿同码鞋,且保趾率高。重建塑形的足、足趾及趾蹼形态接近正常,瘢痕隐蔽,行走无溃疡,达到较好的初期效果。

Objective To evaluate the initial clinical outcome of applying a comprehensive debulking procedure centered on the digital and plantar flaps with comparatively healthy proximal pedicle to reconstruct the hypertrophic toes and forefoots in one-stage surgery in multiple toes macrodactyly in children.Methods The clinical data of children with macrodactyly deformity treated by the Department of Burn and Plastic Surgery in Children’s Hospital of Chongqing Medical University from January 2022 to October 2023 were retrospectively analyzed.Design toe and plantar arbitrary flaps with a few vascular perforating branches which pedicle at the comparatively healthy proximal side and resect all tissues beyond the normal length.In severe toe,a composite tissue nail-flap with the artery was dissected to reconstruct the toenail.Fat debulking on the surface of deep plantar fascia as well as within the osseofascial sheath,resecting partially of the fatty infiltrated nerve,transverse and longitudinal osteotomy to shorten and narrowed phalanxes without epiphyseal block,arthroplasty and flexor tendon tightening were performed.Finally,toes shaped by wrapping toe flaps,and pelmas restored by plantar flaps which both with comparatively healthy proximal pedicle.The operation time,healing time,and whether the toes and toenails are preserved were all recorded.The maximum circumference of both foot,the difference in shoe size,the presence of skin ulcers,wound scars,toe webbing morphology,the presence of basic sensation,and the satisfaction of parents were followed-up after surgery.The modified follow-up questionnaire was used to evaluate the surgical effect,the total score is 0-12 points,and the higher the score,the better the surgical outcome.Descriptive methods was used for statistical analysis,and the measurement data conforming to normal distribution were expressed as Mean±SD.Results A total of 15 patients were enrolled,including 11 males and 4 females.The median age at the time of operation was 2.75 years(0.9-10.8 years).There were 11 cases with 2 toes and 4 cases with 3 toes,a total of 34 toes involved.The average surgical duration was 4.13 hours(3.25 hours for 2 toes and 5.00 hours for 3 toes).Only one severe case with 3 toes involved was amputated the biggest toe ray and totally 2 toe nail flaps were harvested unsuccessfully intraoperative.Except 3 toes had distal skin partially necrosis and 2 nail flaps were completely necrotic which healed after dressing changes,the rest of the toes were healing well after operation.The average follow-up time was 4.8 months(3-11 months),the difference of circumference was less than 1.5 cm,as well as in length was less than 0.5 cm between feet and all children were able to wear the appropriate shoes with same size.A total of 4 toes failed to retain toenails,and 1 had a very thin toenail.Except for one case with insufficient web depth,the other toe webs were close to normal.There was no skin ulcer occurred,the basic sensation of the feet was present,and wound scars were inconspicuous.The score of the modified questionnaire was 10.54±0.88,all parents were satisfied with the results.Conclusion Comprehensive procedure centered on the digital and plantar flaps with comparatively healthy proximal pedicle for debulking multiple toes macrodactyly in children could completely excise distal hypertrophic tissues in a single operation,and the size of the affected feet and toes can be greatly reduced to wearing shoes of the same size,and have a high success rate in preserving the toes,as well as nails.The reconstructed feet,toes and toe webbing have near-normal morphology,hidden scar,no ulcers after walked and achieve a good initial effect.