同指指背动脉穿支皮瓣修复拇指较大面积软组织缺损的疗效观察

目的 探讨同指带桡神经浅支拇指背侧支的指背动脉穿支皮瓣修复拇指较大面积软组织缺损的临床疗效。方法 回顾性分析2015年2月—2019年1月唐山市第二医院手外科16 例(16指)拇指较大面积软组织缺损患者的临床资料。其中男13例,女3例;年龄22~58岁,平均37岁。挤压伤6例,绞伤6例,电锯伤及切割伤4例。拇指单纯掌侧软组织缺损7例,掌侧合并侧方软组织缺损6例,指背缺损3例。受伤至手术时间为 2.0~7.0 h,平均 4.0 h。清创后软组织缺损面积3.3 cm×1.8 cm~6.0 cm×2.8 cm。采用大小为3.6 cm×2.1 cm~7.0 cm×3.2 cm 的同指指背动脉穿支皮瓣逆行修复,同时将皮瓣携带的桡神经浅支拇指背侧支与创面内的指固有神经残端吻合。供区12例直接拉拢缝合,4例残留小面积创面行全厚游离皮片植皮修复。术后观察皮瓣成活情况,观察末次随访时皮瓣血运、外观、质地及静态两点辨别觉,对比伤指与健侧掌指关节和指间关节总活动度(TAM)及虎口角。结果 术后1例皮瓣表面出现水泡,拆除蒂部部分缝线,经换药后皮瓣成活。其余15例皮瓣顺利成活。16例均获随访,随访时间10~24个月,平均14个月。皮瓣外观良好,质地柔软,与周围组织相近,耐磨、耐寒冷。皮瓣静态两点辨别觉为8~13 mm。伤指TAM为138°±3.9°、健侧为140°±3.4°,伤侧虎口角度为95°±10.3°、健侧为96°±9.2°,两侧比较差异均无统计学意义(t=1.861、1.732, P值均>0.05)。供区仅残留线性瘢痕。结论 同指背侧带桡神经浅支拇指背侧支的指背动脉穿支皮瓣可逆行修复拇指多个部位较大面积软组织缺损,操作简单、疗效满意,供区损伤小,适合基层医院推广应用。

Observation of the curative effect of homodigital dorsal digital artery perforator flaps for repairing large soft tissue defects of the thumb

Objective To investigate the clinical outcomes of homodigital dorsal digital artery perforator flaps innervated by thumb dorsal branches of the superficial branch of the radial nerve to repair large soft tissue defects of the thumb.Methods From February 2015 to January 2019, 16 patients (16 thumbs) with large soft tissue defects of the thumb were hospitalized in the Second Hospital of Tangshan. Of the 16 patients, 13 were males and 3 were females, with an mean age of 37 years (range, 22-58 years). The causes of the injury included crush injury in 6 cases, twisted injury in 6 cases, and electric saw and cut injury in 4 cases. Meanwhile, 7 cases of simple palmar soft tissue defects, 6 cases of palmar and lateral soft tissue defects, and 3 cases of dorsal digital defects were involved. The interval between injury and operation ranged from 2 h to 7 h (mean, 4 h). The soft-tissue defect sizes of the thumb after debridement ranged from 3.3 cm×1.8 cm to 6.0 cm×2.8 cm. The dimension of the flaps ranged from 3.6 cm×2.1 cm to 7.0 cm×3.2 cm. All defects were repaired using homodigital dorsal digital artery perforator flaps. The dorsal branches of the superficial branch of the radial nerve in the flaps were anastomosed with the proper digital nerve stumps in the wound. The wounds of the donor site were closed primarily in 12 cases and were repaired with the full-thickness skin graft in 4 cases. The survival of the flap was observed after operation. The blood flow, appearance, texture and two points' static discrimination of the flaps were observed , and the total range of motion of metacarpophalangeal joint and interphalangeal joint were compared between the injured finger and the healthy one at the last follow-up. Results Postoperative blister occurred in 1 case,the flap healed with removing some stitches of the pedicle;the other 15 cases survived successfully. The mean follow-up time was 14 months (range, 10-24 months). The appearance of the flaps matched the surrounding tissue with satisfactory appearance, soft texture, resistant wear, and cold. The static 2-point discrimination was 8-13 mm. The total range of motion of the metacarpophalangeal and interphalangeal joints of the injured finger and the healthy side was 138°±3.9° and 140°±3.4°, and the angles of the injured and uninjured sides were 95°±10.3° and 96°±9.2°, respectively, with no statistical difference (t=1.861, 1.732, all P values>0.05). A slightly linear scar was left at the donor area of the dorsal thumb.Conclusions Homodigital dorsal digital artery perforator flaps innervated by the thumb dorsal branches of the superficial branch of the radial nerve provide a reliable and simple technique with satisfactory therapeutic effect and minimal donor site cost. Thus, this technique is a good option for repairing large soft tissue defects of different sites in the thumb in primary hospitals.