静脉移植治疗足趾再造拇手指术后顽固性动脉痉挛

目的 介绍静脉移植在足趾移植再造拇手指后发生顽固性动脉痉挛中的应用效果。方法 对6例7趾和皮瓣移植术中、术后动脉顽固性痉挛，经其它方法处理仍不缓解，切除痉挛段动脉应用静脉移植恢复血供。结果 6例7个足趾移植后全部成活，仅皮瓣的远端坏死。结论 该方法是处理足趾移植术后顽固性动脉痉挛的一种可行方法。     

即时断蒂治疗足趾移植顽固性动脉痉挛

目的 介绍即时性断蒂在足趾移植术中发生顽固性动脉痉挛时应用的可行性。方法 对5例足趾移植术中动脉顽固性痉挛（其中150min1例，120min2例，90min1例，60min1例）不缓解即时断蒂移植。结果 5例移植足趾全部成活。结论 足趾移植时即时性断蒂是解决手术中顽固性动脉痉挛的有效方法，其作用机制尚待进一步研究。     

拇手指末节部分缺损的修复与再造

目的报道应用吻合血管的足趾游离移植修复与再造拇、手指末节部分缺损的临床效果。方法采用吻合趾-指动、静脉的第二足趾游离移植或趾皮瓣游离移植修复与再造拇、手指末节部分缺损45例45指，其中：游离第二足趾12例、躅趾腓侧皮瓣游离移植4例、躅趾趾腹皮瓣游离移植3例、第二足趾胫侧皮瓣游离移植6例、第二足趾趾腹皮瓣游离移植5例、躅甲瓣游离移植3例、趾甲瓣游离移植7例、趾甲瓣加伸肌腱复合组织移植游离移植5例。结果术后45例全部成活，得到随访41例，外形满意，功能较好。结论拇、手指末节部分缺损采用足趾移植的方法进行修复与再造可获比较满意效果。     

15例游离足趾再造手指失败原因的分析及改进方法

目的 对15例游离足趾拇手指再造失败的原因进行分析并提出改进的方法。方法 1988年5月至2000年3月，利用游离足趾移植再造拇、手指351例。对其中15例拇、手指再造失败者进行了分析。结果 15例移植的均为第二足趾。足趾组织中第一跖背、跖底动脉吻合处及吻合后发出分支的形式和发至第二足趾趾动脉的管径细小是引起手术失败的主要原因(9／15)。结论 术中保留第二套供血系统，是解决第一跖背动脉和受动脉常规吻合后引起“顽固性痉挛”的最佳方法。     

第二足趾或(足母)甲皮瓣的延迟移植

用自体足趾或[足母]甲皮瓣游离移植再造拇、手指已成为临床广泛应用的治疗方法，在完成对第二足趾或[足母]甲皮瓣游离未断蒂时，常会遇到足背动脉与第一跖骨背动脉（First Dorsal Metacarpal Artery FDMA）顽固性痉挛，足趾或皮瓣处于干瘪与苍白的状态，经过局部热敷、血管扩张药的应用以及剥离血管外膜等措施仍不好转的现象。     

带足背皮瓣的第二足趾游离移植再造拇手指

目的 报道应用带足背皮瓣的第二足趾游离移植再造拇手指Ⅳ度缺损的临床效果.方法 根据不同程度拇手指皮肤缺损大小及形状,设计以足背动脉及大隐静脉为血管蒂的带足背皮瓣的第二足趾游离移植再造拇手指12例12指,其中拇指7例7指,示指3例,中、环指各1例.急诊手术4例,择期手术8例.足背皮瓣切取最大面积为8cm×5 cm,最小为5 cm x 3 cmc.结果 再造拇手指12例12指全部成活.其中最早1例拇指再造因切取足背皮瓣稍小,辅以中厚皮片植皮,亦成活.经4个月～3年随访,按手外科学会手指再造功能评定标准,优良率为75%.再造指体与正常拇手指长度相近,皮肤质地良好,外形较好.手指恢复较好的抓、捏、弹功能.结论 应用带足背皮瓣的第二足趾游离移植是修复再造拇手指IV度缺损较为理想的方法之一.     

足部动脉系统解剖学研究与以跖底动脉为蒂足部组织游离移植术

目的寻求一种更为安全、有效的足部组织游离移植再造拇、手指及关节功能的新方法,进一步提高手术成功率。方法对足部跖底与跖背动脉系统进行显微解剖学研究。设计并应用逆行游离、吻合跖底动脉的足部组织游离移植术治疗76例拇、手指及手部关节缺损患者,其中第二足趾移植58例,第二足趾复合组织移植4例,近侧趾间关节移植8例,(?)甲瓣移植6例。分析总结其疗效。结果第一跖底动脉解剖恒定,到第二足趾的分支粗于第一跖背动脉。75例患者全部成活,移植部位外观良好,功能明显改进,总成活率为98．7%。另1例行第二足趾游离移植再造拇指术患者因顽固性动脉痉挛而改用锁骨下皮管包埋。结论应用逆行游离跖底动脉为蒂的足部组织游离移植术可以克服其它方法存在的血管解剖变异较大、操作复杂、费时等不足,提高了手术效率和成功率。     

游离足趾移植急诊拇手指再造106例

目的总结游离足趾移植急诊拇手指再造的临床经验,进一步探讨游离足趾移植急诊拇手指再造的可行性.方法 1997年1月～2005年2月收治外伤性拇手指缺损患者106例,清创后,采用（足母）趾移植急诊再造拇指8例,第二足趾移植再造拇指69例、再造中指7例、再造食指4例、再造环指3例、再造手1例,双侧第二足趾移植同时再造拇食指3例、再造食中指7例、再造中环指3例、再造手1例.结果再造拇手指106例119指成活118指,无一例感染,经3～66个月随访,所有再造拇手指血运丰富,感觉恢复良好,对指和对掌灵活.结论对于外伤性拇手指缺损,经过彻底清创,科学设计,采用游离足趾移植急诊再造,可以获得满意的再造效果.     

游离足趾移植再造拇手指术的护理

目的探讨和总结游离足趾移植再造拇手指术的护理,以提高其成活率。方法根据游离足趾移植再造拇手指术的手术治疗、护理特点,不断完善制定术前、术后护理措施,并对该手术患者认真实施、观察效果。结果通过认真执行各项护理措施、术前准备充分、术后并发症发现及时处理,游离足趾移植再造拇手指成活。结论游离足趾移植再造拇手指术的护理,增强了护理工作的水平和能力,提高了再造拇手指成活率,功能基本正常。     

静脉动脉化在手指再植与再造中的应用

目的探讨静脉动脉化再植与再造修复手指创伤的方法。方法对手指斜行离断伤、复合组织块离断伤、套脱伤，离断的部分不含动脉或动脉血管纤细无法吻合，或技术因素经多次动脉吻合失败，无法再吻合时，采用静脉动脉化再植，共7例8指。在切取拇甲瓣或第二足趾再造拇、手指时，由于血管变异无法携带可吻合的动脉进行移植、移植术中多次吻合动脉失败或术后发生动脉广泛栓塞，无动脉可再吻合时，改用静脉动脉化修复血管，共2例。结果9例全部成活。术后随访6个月．3年，功能恢复：优5例，良3例，可1例，优良率达89％。结论静脉动脉化手指再植与再造，对无法行动脉吻合的手指及复合组织离断伤，是一种可行的治疗方法。对游离足趾或足趾复合组织移植再造手指术，若动脉系统出现问题，该方法是挽救指体的一种补救措施。     

拇指及手指再造手术血管危象164例临床分析

目的探讨拇、手指再造血管危象的诱因、处理方法与预防措施。方法复习164例拇、手指再造血管危象的病历，分别记录血管危象的类型、发生时间、诱发原因、处理方法与转归，并对结果进行统计、分析。结果本组血管危象发生率为18．4％。其中动脉栓塞85例，动脉痉挛52例，静脉栓塞6例，静脉痉挛14例，动静脉均栓塞7例，经处置后，缓解150例188指，坏死14例14指，处置成功率为93．1％(188／202)。结论拇、手指再造血管危象的及时、恰当处置对提高手术成功率至关重要。为了减少血管危象的发生，应采取适当的预防措施。     

Reverse radial forearm flap as a source of soft tissue and blood supply for thumb reconstruction

Soft-tissue deficiency is sometimes a major problem in thumb reconstructive cases with toe-to-thumb transfer. In the patient presented, a reverse radial forearm flap was used to provide a vascular pedicle for anastomosis with the second toe vessels. The flap also provided soft-tissue coverage for the metatarsal bone of the transferred toe. The radial artery and concomitant vein were used for the dorsalis pedis artery and vein anastomosis. The skin island of the forearm flap was wrapped around the transferred metatarsal bone. Using this technique, two limiting problems in toe-to-hand transfers were solved at the same time. In the crushed hand, sometimes it is not possible to find enough soft tissue and a good vascular pedicle for a new thumb, and this option seems to be a reasonable choice.     

Temporary arteriovenous loop between the saphenous vein and the first plantar metatarsal artery in toe-to-hand transfers

We describe a technique for creating a temporary arteriovenous loop by anastomosing the saphenous vein to the first plantar metatarsal artery to facilitate harvesting and subsequent anastomosis of a great or second toe transfer. This technique has been used in 9 patients: 6 pediatric toe-to-hand transfers for congenital hand differences and 3 adult toe transfers for a thumb amputation. All 9 toe transfers survived. The advantages of this technique are that it allows precise determination of the exact length of the loop to reach the recipient artery, it facilitates palmar positioning of the arterial pedicle, and, if necessary, the saphenous vein can be anastomosed directly to the lateral digital artery of a great toe transfer or the medial digital artery of a second toe transfer rather than the first plantar metatarsal artery itself, thereby minimizing more proximal dissection of the first plantar metatarsal artery, which is more difficult and time consuming.     

The arterial system of the first intermetatarsal space and its influence in toe-to-hand transfer: a report of 53 long-pedicle transfers

A study of the arterial system in the first intermetatarsal space was performed during 53 toe-to-hand or vascularized tissue of the toe transfers with long arterial pedicles. The first dorsal metatarsal artery was used as a single pedicle in 25 transfers and the first plantar metatarsal artery in 21: both arteries were taken simultaneously in seven transfers. In 11 transfers, the dorsalis pedis artery and the perforating branch were absent, although this did not exclude the presence of a first dorsal metatarsal artery which arose from the plantar system by means of an ascending vascular branch in seven cases.     

第三趾胫侧趾动脉皮瓣联合第二足趾移植改善再造手指外形

目的 探讨携带第三趾胫侧趾动脉皮瓣弥补第二足趾移植时因足趾趾腹膨大、趾体狭细而导致的外形缺陷.方法 对9例10指拇、手指缺损的患者,在第二足趾移植再造拇、手指的同时,于第三趾胫侧设计并切取趾动脉皮瓣,嵌插于第二足趾中末节跖侧,增加第二足趾的周径使其接近正常拇、手指周径,同时修整趾腹,使再造拇、手指外形更接近正常.方果 术后9例10指再造拇、手指全部存活,再造指中段周径增加了6～8mm,外形明显改善.方论 第三趾胫侧趾动脉皮瓣血管恒定,切取方便,厚度适中;于第二足趾移植再造拇、手指时可一并切取,修饰第二足趾的外形,弥补再造拇、手指的外形缺陷.     

延迟性足趾移植的临床及实验研究

目的 介绍延迟性足趾移植的方法，指片并探讨其机制。方法 为１０例足趾移植术中发生血液循环危象的病例进行了延迟手术，手术后１７－２１小时断蒂进行移植。实验应用３６只大白兔后肢离断保留血管蒂模型，于术后４，８，１６，２４小时对局部肢体组织及动脉壁进行内皮素（ＥＴ）及一氧化氮（ＮＯ）含量检测，全部数据作统计学处理。结果 临床１０例延迟性足趾移植术全部成活。     

拇手指再造供区(足母)趾坏死的原因及预防措施

目的 对3例拇手指再造供区(足母)趾坏死的原因进行分析并提出预防措施.方法 自1998年2月至2005年2月,在我院行游离足趾移植再造拇手指中,3例供区(足母)趾部分坏死.通过分析(足母)趾血供的来源及术中采用血管阻断实验,分析供区(足母)趾部分坏死的原因,提出预防措施.结果 3例供区(足母)趾部分坏死,第1跖骨背动脉均为Ⅲ型,术中均采用足背动脉-足底深动脉-第1趾足底总动脉这一途径来切取第2趾.发现供区(足母)趾坏死时间为术后8～21 h.术中同时损伤(足母)趾腓侧趾背动脉、腓侧跖底动脉,将严重影响供区(足母)趾血液循环,术后供区包扎过紧、观察不到位,是导致供区(足母)趾坏死不可忽视的原因.结论 第1跖骨背动脉Ⅲ型,解剖足底动脉于跖底的"X"形交叉处,切取第2足趾,更易影响供区(足母)趾血运.采用吻合足底深动脉与跖底动脉或足背动脉-第2跖背动脉-趾动脉为血供切取足趾,可有效预防供区(足母)趾血运被破坏;术中、术后严密观察供区足的血运情况,及时解除(足母)趾压迫,是预防供区(足母)趾坏死的有效途径.

Abstract：

Objective To analyze the causes of necrosis of the donor great toe in 3 cases of toe-to-hand transfer and propose the proper preventive measures.Methods Among all the toe-to-hand transfers done from February 1998 to February 2005, partial necrosis of the donor great toe occurred in 3 cases.Blood supply of the transferred toe and the intraoperative vessel occlusion test was reviewed and analyzed to define causes of the necrosis, and propose preventive measures accordingly.Results The dorsal artery of the great toe was type Ⅲ in all 3 cases.Intraoperatively the second toe was harvested based on the dorsalis pedis artery, deep plantar artery, plantar artery of the first toe.Donor great toe necrosis was observed 8 to 21 hours postoperatively.Intraoperative inadvertent injury of the dorsal great toe fibular artery and fibular plantar metatarsal artery, tight dressing of the donor site after the surgery, and poor postoperative monitoring could have contributed to the toe necrosis.Conclusion Type Ⅲ of the dorsal artery of the great toe, anatomical X cross and resection of the second toe could easily affect blood supply to the donor great toe.Anastomosis of the deep plantar artery and the plantar metatarsal artery, or harvest of the toe based on the dorsalis pedis artery, second dorsal metatarsal artery,digital artery axis can effectively prevent damage of the blood flow.Intra-and post-operative close monitoring of the donor site circulation and timely decompression of the great toe were effective ways to prevent great toe necrosis.     

吻合血管术后55例血管危象探查体会

目的 对吻合血管术后55例(63次)血管危象进行临床分析.方法 对2004年4月至2007年12月在我院手外科有完整资料的55例(63次)发生血管危象的病例资料进行回顾性分析,其中断指再植29例、足趾移植手指再造17例、游离皮瓣8例、手指不全离断1例.所有病例均经保守治疗1h后血管危象无缓解而进行手术探查,根据术中所见血管情况进行相应处理,其中26例30次动脉栓塞、17例20次动脉痉挛、10例11次静脉栓塞、2例2次血管受压;其中包括动脉张力过低1例、静脉张力过高1例、动脉分支未结扎1例.根据术中所见,20例23次行前臂浅静脉血管移植,33例38次行栓塞段血管切除重新吻合,1例修剪压迫组织,1例清除局部血肿.结果 本组55例,存活51例,成活率92.73％.其中坏死的有断指再植2例,足趾移植手指再造1例,游离皮瓣1例.结论 血管吻合术后一旦发生血管危象,经保守治疗无效后,早期、积极地手术探查是挽救的关键措施.     

Free toe transfer with plantar metatarsal arteries and dorsal venous pedicle. Report of 18 cases

Eighteen free second toe were used for pollicization other than the conventional method. From the first and second plantar metatarsal arteries junction of the both digital arteries of the second toe were dissected retrogradely and anastomosed to the deep of superficial palmar arch or terminal branch of the radial artery. The venous return was established between the dorsal venous arch and cephalic vein. These vessels were found to have much bigger diameters and less anatomical variation than those used by conventional methods. Seventeen transplantation were considered successful both functionally and cosmetically. One cases had persistent spasmodic contraction of the recipient arteries, so the transplant was salvaged by subclavicular pedicle including the sutured nerves and the attached soft tissues as introduced by Lu in 1964. Our method for reconstruction of the thumb or finger can avoid frequent anatomical variation and smaller diameter of the anastomosed vessels.