联体尺动脉穿支皮瓣在多指毁损伤修复中的临床应用

目的探讨联体尺动脉穿支皮瓣修复多指毁损伤的临床效果。方法回顾性分析2011年3月至2017年10月东莞长安新安医院收治的12例多指毁损伤患者,男8例,女4例,年龄(32.6±4.3)岁,范围18~56岁。4指毁损伤2例,3指毁损伤4例,2指毁损伤6例。皮肤软组织损伤位置均为远掌横纹或指掌横纹以远,指骨为近节以远。皮肤总缺损面积(135.6±12.3)cm^2,范围6.0 cm×16.0 cm^6.0 cm×35.0 cm,应用皮瓣总面积(143.5±11.2)cm^2,范围5.0 cm×20.0 cm^3.2 cm×47.0 cm(双侧前臂)。双前臂尺动脉穿支皮瓣5例,单侧7例,所有皮瓣均为2条以上穿支蒂。皮瓣均设计为长条状,螺旋缠绕包裹于伤指骨,皮瓣穿支动脉与相应指固有动脉或掌背动脉吻合,伴行静脉与相应指掌侧静脉或掌背静脉吻合,皮瓣浅静脉与相应指背静脉或掌背静脉吻合,皮瓣神经与相应指固有神经或掌背相应感觉神经吻合。供区除1例植皮外,其余均直接缝合。术后随访观察疗效,包括感觉、外观、血液循环、骨吸收及手运动功能、日常生活、恢复工作情况等。评价标准为中华医学会手外科学会断指再植功能评定试用标准。结果所有皮瓣均成活,1例皮瓣末稍有约1.5 cm×1.5 cm坏死,二期缝合修复。所有病例均获6个月至6.5年随访,平均16.7个月,皮瓣质地良好,无色素沉着,外观无臃肿,指端无瘢痕或磨损,两点辨距觉6~10 mm,平均8.6 mm。术后半年骨吸收发生率59.4%(19/32),指短缩平均0.8 cm,其中5例6指取髂骨植骨。伤指拿捏及持物功能部分恢复,日常生活无明显影响;患手握力平均达到健侧的60.3%。参照断指再植功能评定试用标准:优2例,良5例,差4例,劣1例,优良率58.3%(7/12)。供区外观可。结论联体尺动脉穿支皮瓣为多指毁损或脱套伤患者的临床修复提供了一种有益的思路和有效的手术方案,效果良好。     

Diagnostic sensitivity of electrophysiology and ultrasonography in ulnar neuropathies of different severity

ObjectiveTo assess the diagnostic performance of electrophysiology and nerve ultrasound in ulnar neuropathies of varying clinical severity in 135 consecutive patients.MethodsClinical severity of ulnar neuropathy was graded on a 4 point scale from very mild (symptoms only) to severe (marked atrophy of intrinsic hand muscles). Sensitivity and localization ability of electrophysiology and nerve ultrasound were assessed for each point of the scale.ResultsUltrasound had higher sensitivity than electrophysiology in clinically very mild (20% and 3% for ultrasound and electrophysiology, respectively) and mild (62% and 47% for ultrasound and electrophysiology, respectively) neuropathies, had greater localizing ability in axonal ulnar neuropathies, and identified nerve hypermobility.Ultrasound nerve cross-sectional area had strong positive correlation with both clinical and electrophysiological severity scores, but with significant overlap across the severity groups.ConclusionThe diagnostic work-up of ulnar neuropathies was improved by using both electrophysiology and ultrasound at all levels of clinical severity. Ultrasound increased the diagnostic yield in very mild and mild neuropathies, localized all the ulnar neuropathies with abnormal non-localizing electrophysiology and identified nerve hypermobility.SignificanceThis is the first detailed analysis of the diagnostic performance of electrophysiology and ultrasound in ulnar neuropathies of varying severity.     

Differentiation of ulnar neuropathy at the wrist due to ganglion cyst from ulnar neuropathy at the elbow

ObjectiveHere, we aimed to describe the clinical, electrodiagnostic (EDx) and ultrasonographic (US) findings in a series of patients with ulnar neuropathy at the wrist (UNW) due to compression by a ganglion cyst. We also sought features that differentiate UNW from ulnar neuropathy at the elbow (UNE).MethodsWe reviewed electronic medical records of consecutive patients with UNW caused by ganglion cysts. We compared their clinical, EDx and US findings to findings in our previously reported prospective series of UNE patients.ResultsWe identified 10 patients with UNW caused by ganglion cyst compression, who all presented with intrinsic hand muscle weakness and atrophy. Compared to 175 UNE patients they less often complained of paresthesia (60% vs. 98%) and presented less sensory loss in the palm (30% vs. 96%) and little finger (50% vs. 95%). They more often had distal ulnar motor latency recorded from the abductor digiti minimi (ADM) > 3.6 ms (80% vs. 30%), and denervation activity on needle EMG in the first dorsal interosseous (FDI) compared to ADM (100% vs. 60%). Only 20% of our UNW patients had ulnar nerve swelling at the site of compression on US.ConclusionUNW potentially caused by ganglion cyst should be suspected in patients presenting with intrinsic hand muscle atrophy and weakness, particularly in cases with normal sensation, increased distal ulnar motor latency recorded from ADM and more severe neuropathic changes in FDI compared to ADM muscle.     

桡骨远端FrykmanⅧ型骨折钢板固定有限元模型的建立及力学分析

文题释义：尺骨茎突骨折：高达50%-70%的桡骨远端骨折合并有尺骨茎突骨折，骨折预后由此产生的并发症已经引起了临床的重视，但对尺骨茎突骨折是否需要固定仍存在争议。桡骨远端骨折Frykman分型：由Frykman于1967年提出，8种分型中的偶数型均合并有尺骨茎突骨折。背景：临床中对于桡骨远端骨折或是关节脱位的治疗普遍比较重视，但却很少关注尺骨茎突骨折，而且对尺骨茎突骨折是否需要固定存在争议。骨科生物力学研究中，选用尸体实验可能会遇到尸体模型选择标准不一以及力学测量手段不同等问题。 目的：选用有限元分析方法，基于Mimics软件构建桡骨远端Frykman Ⅷ型骨折钢板螺钉固定的有限元仿真模型，并设定工况与载荷进行力学分析，希望给此类骨折修复方案的选择提供参考。方法：基于1例健康志愿者的前臂及手部CT图像建立正常腕关节三维有限元基础模型，调试后通过轴向加载100 N应力得出桡骨远端的应力分布云图，与文献中尸体实验数据对比来验证模型的有效性。通过有限元相关软件分网、切割造模建立桡骨远端Frykman Ⅷ型骨折合并尺骨茎突Ⅰ型和Ⅱ型骨折的2种有限元模型，并完成桡骨远端钢板螺钉固定模型的组装。在旋转工况下设定载荷，分析2个模型中钢板内植物单元的应力分布、下尺桡关节的相对位移及尺骨茎突骨折端位移的变化情况。结果与结论：①建立并验证了正常腕关节的三维有限元模型，以此为基础延伸建立出桡骨远端Frykman Ⅷ型骨折合并尺骨茎突Ⅰ型和Ⅱ型骨折桡骨远端钢板螺钉固定的2种有限元模型；②在设定相同旋转载荷条件下，桡骨远端Frykman Ⅷ型骨折合并尺骨茎突Ⅰ型骨折的钢板固定模型中钢板单元承受的应力及应力分布范围均小于合并尺骨茎突Ⅱ型骨折钢板固定的骨折模型，下尺桡关节的相对位移值及尺骨茎突骨折端位移值也小于后者；③提示构建的腕关节三维有限元模型可用于腕部骨折的力学机制分析；通过有限元分析研究显示，桡骨远端Frykman Ⅷ型骨折中尺骨茎突骨折会影响下尺桡关节的稳定性，其中合并有尺骨茎突Ⅱ型骨折时较为明显，可以给此类骨折修复方案的选择提供一定的临床参考。ORCID: 0000-0001-7298-6727(李永耀) 中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程