前臂及手严重毁损早期功能重建

介绍１９９２年１２月～１９９５年２月收治８例按传统概念需截肢的前臂及手部严重毁损伤施行的早期功能重建术。按毁损部位及程度采用：（１）前臂毁损段修整，残掌残指异位中段再植；游离第２足趾带足背皮瓣、小腿外侧联合皮瓣再造拇指及修复创面；（２）残指异位再植，游离第２足趾带足背皮瓣再造拇、手指及修复创面：（３）断掌毁损无法再植，用游离第２足趾带足背皮辩再造拇指于第１腕掌关节，皮瓣修复创面，并行第２掌骨示指化。随访６个月～２年，均恢复手的部分功能，回到工作岗位。我们认为对严重毁损手，只要条件许可，应尽量利用复合组织移植，急诊或早期施行异位再植及功能重建术。     

前臂及手严重毁损早期功能重建

介绍１９９２年１２月－１９９５年２月收治８例按传统概念需截肢的前臂及手部严重毁损伤施行的早期功能重建术。按毁损位及程度采用：（１）前臂毁损段修整，残掌残指异位中段再植；游离第２足趾带足背皮瓣、小腿外侧联合皮瓣再造拇指及修复创面；（２）残指异位再植，游离第２足趾带足背皮瓣再造拇、手指及修复创面；（３）断掌损无法再植，用游离第２足趾带足背皮瓣再造拇指于第１腕掌关节，皮瓣修复创面，并行第２掌骨示指化。随     

腕、掌部毁损的急诊手再造

目的 报告腕、掌部毁损伤利用残指移位再植于前臂远端急诊手再造的经验和方法.方法 对4例腕、掌部毁损伤的患者,利用显微外科技术将残指移位再植于桡、尺骨远端,结合术后系统的功能锻炼,重建部分手功能.结果 4例再造手全部存活.随访时间最长20年,最短1年;再造手恢复了部分屈伸、握持、对掌功能,指腹两点分辨觉为5～7mm.结论 对于腕、掌部毁损伤的患者,将残指移位再植于前臂残端,重建手指屈伸和对掌功能,是治疗该类损伤较为理想的方法.     

再植联合手再造术修复腕掌部毁损性离断伤

目的 报告再植联合手再造术修复腕掌部毁损性离断伤的治疗方法.方法 对5例腕、掌部损毁伤患者利用残掌、指移位再植于前臂远端进行再植联合手再造术,术后行针对性康复锻炼.结果 5例再造手全部存活,术后随访时间平均24个月,再造手具备抓握等基本功能,指腹两点分辨觉为5～8 mm.结论 急诊再植联合手再造术、术后针对性康复锻炼是腕、掌毁损伤后治疗及恢复功能的理想方法.     

再植联合手再造术修复腕掌部毁损性离断伤

目的 报道再植联合手再造术修复腕掌部毁损性离断伤的治疗方法.方法 对5例腕掌部损毁伤患者利用残掌、指移位再植于前臂远端进行再植联合手再造术.结果 5例再造手全部成活,术后随访24个月,再造手均具备抓握等基本功能,指腹两点辨别觉5-8mm.结论 急诊行再植联合手再造术及术后行针对性康复训练是腕掌损毁伤后进行治疗及功能恢复的理想方法.     

急诊一期组合组织移植再造手

目的:采用吻合血管组合组织移植一期修复手部大范围多元组织缺损再造手。方法:①指缺失:用第2足趾或躅甲瓣再造拇指,用第2、3足趾再造其它手指。②软组织缺损:虎口及手掌皮肤缺损用股前外侧皮瓣修复并同时用股前外侧皮神经重建受区感觉功能,大范围皮肤缺损则用股前外侧皮瓣组合其它皮瓣修复。③掌指关节及掌骨缺损:掌指关节缺失用跖趾关节重建,掌骨缺失用跖骨或髂骨重建。结果:33例75个游离组织全部成活,再造手功能恢复良好,皮肤感觉恢复。结论:吻合血管组合组织移植一期再造手,具有最大限度的保留手部残存非失活组织及功能,最大限度修复重建手部功能的优点,是理想的治疗方法。     

游离组织移植在上肢创伤中的应用

我们应用带血管的游离组织移植，修复上肢外伤后软组织缺损１０例，移植皮瓣及复合组织全部成活，疗效较为满意。一、资料与方法本组１０例，均为手部及前臂损伤后软组织缺损行晚期修复的患者。由于在修复创面的同时，需作功能重建，故采用复合组织移植最合适。手术方法：（１）游离足趾移植再造拇指２例，再造拇指成活。感觉恢复，能对指。（２）带跖骨及肌腱的足背皮瓣移植。修复左手第３掌骨及掌侧软组织缺损１例；右拇指大部指骨及软组织缺损１例。皮瓣及骨片均全部成活。（３）足背皮瓣带肌腱的复合组织游离移植，修复前臂软组织及伸指…     

髂腹股沟真皮下血管网皮瓣修复手指毁损伤30例病例分析

目的:探讨髂腹股沟真皮下血管网皮瓣修复手指毁损伤后外观及功能恢复情况。方法:2008年2月～2013年1月我科应用髂腹股沟真皮下血管网皮瓣修复手指毁损伤病例30例32指。术中彻底清创,克氏针内固定指骨骨折端,髂腹股沟真皮下血管网皮瓣包裹指骨,Ⅰ期修复手指毁损伤创面。结果:30例患者髂腹股沟真皮下血管网皮瓣全部成活,手术效果良好,术后患指外形及功能恢复良好。结论:应用髂腹股沟真皮下血管网皮瓣修复手指毁损伤,术后患指外观及功能恢复良好。     

毁损性手外伤的早期修复与功能重建

目的 寻找手部大范围多元组织毁损后组织修复及功能重建的最佳方法。方法 １９９０年１月～１９９９年６月,采用急症（３３例）、亚急症（伤手三天内,２６例）吻合血管的组织移植或复合组织移植的方法一期修复毁损组织并重建手部功能。对手部桡侧的再造采用皮瓣与足践组合时于皮瓣局部打孔的方法将再造拇指引出,解决虎口瘢痕挛缩;百游离第二足趾的同时游离仲、伸趾短肌或短展肌或短肌组合移植重建再造拇指对掌功能,对常区无可     

急诊一期组合组织移植修复手部严重创伤及重建部分手功能

目的报道急诊一期组合组织移植修复手部严重创伤及重建部分手功能的临床应用效果。方法(1)指缺失:用第2足趾、(足母)甲瓣或残存手指再造拇指,用第2、3足趾或残存手指再造其他手指。(2)软组织缺损:虎口及手掌皮肤缺损用股前外侧皮神经重建受区感觉功能,大范围皮肤缺损则用股前外侧皮瓣组合其他皮瓣修复。(3)掌指关节及掌骨缺损:掌指关节缺失用跖趾关节重建,掌骨缺失用跖骨重建。结果16例34个游离组织全部成活,仅1块部分坏死清创换药后治愈,术后获5个月~9年的随防,再造的手指均恢复了触、温、痛觉,两点辨别觉在5~15mm左右。修复伤手的所有皮瓣均恢复了保护性感觉。结论急诊一期吻合血管组合组织移植修复手严重创伤具有最大限度的保留手部残存非失活组织及功能,最大限度修复重建手部功能的优点,是理想的治疗方法。     

Microsurgical reconstruction of the scaphoid and lunate bones with small, free vascularized iliac crest bone grafts

The primary surgical goal in repairing a scaphoid nonunion, particularly one associated with avascular fragments, or reconstructing the lunate is to prevent progressive carpal collapse. In patients with persistent nonunion of the scaphoid and progressive aseptic necrosis of the lunate bone, reconstruction can be managed with a small microvascular iliac crest bone transfer. This retrospective study reports on the anatomical fundamentals, the operative procedure (particularly the harvesting of the bone flap and microsurgery), the assessment of the viability of the bone graft and the postoperative results in 80 out of a total of 210 patients on whom the surgery had been performed. From 1985 until 1998, 210 carpal bone reconstructions (134 scaphoid bones and 76 lunate bones) were performed using small, free vascularized iliac crest bone grafts. Of these, 80 patients were preoperatively evaluated and postoperatively followed up clinically and by means of conventional radiography and magnetic resonance imaging (MRI). The total rate of viability and bony union was 91.2%. This means a bone flap loss-rate and, consequently, a progressive arthrosis/necrosis/persistent nonunion of 8.8%. The patients who had vital reconstructed carpal bones did not report pain, but motion and grip strength were decreased as compared with the uninvolved side. This procedure offers stability and vascularity to treat avascular scaphoid nonunion and has proved beneficial in achieving union in avascular scaphoid pseudoarthrosis and lunate necrosis. It can be considered to be the definitive alternative technique. The high rate of union and the absence of progressive carpal arthrosis are the best evidence for the vascularity of the bone graft.     

Recurrent osteoblastoma of the hamate bone. A two-stage reconstruction with a free vascularized iliac crest flap.

An osteoblastoma in a carpal bone is very rare and presents a problem of reconstruction after wide tumour excision. We report a case of recurrent osteoblastoma of the right hamate bone with involvement of the ulnar carpal bones and soft tissues that was successfully treated by en bloc resection, temporary interposition of bone cement and fixation with K-wires, followed by reconstruction with a free vascularized iliac crest flap, tailored to the exact size of the defect, in a second procedure. Rapid fusion was achieved and hand function preserved with no evidence of recurrence 3 years postoperatively.     

Wrist arthrodesis with intercalated iliac crest graft in mutilans rheumatoid arthritis

In mutilans rheumatoid arthritis (RA) patients with major wrist destruction, wrist arthrodesis is recommended. This type of arthrodesis needs carpal reconstruction and stable fixation. The goal of this study was to assess the functional and anatomical outcomes of an iliac crest graft and internal fixation with two medullary pins. Six wrists in three patients suffering from RA were reviewed clinically and radiologically at an average follow-up of 25 months. We assessed the fusion of the iliac graft with the radius and the metacarpus, the preoperative and postoperative carpal height, and the bone stock in front of the thumb. All the patients had improved functionally. The iliac graft fused with the radius in all cases and fused with the metacarpus in 5 out of 6 cases; the non-union occurred in the wrist where only one pin was used. Restoration of carpal height was associated with improvements in hand function. The bone stock was sufficient to allow implantation of a trapezial cup during a total arthroplasty of the thumb trapeziometacarpal (TMC) joint. No major complications occurred. An iliac graft and two pins through the 2nd and 3rd metacarpals were used to reconstruct the carpal height and to obtain wrist fusion. Internal fixation with only one pin is not recommended. Functional improvement can be attributed to the normal tension within the extrinsic flexors and extensors of fingers and thumb being restored because the carpal height was restored. A secondary TMC arthroplasty is theoretically possible.     

Osseous vascular anatomy in the hand and wrist

The design and the realization of vascularized osseous grafts at the hand and the wrist require a precise knowledge of the general and regional anatomy. This article gives first a progress report on current knowledge about the general organization of arterial and venous vascularization, of the long bones (number and localization of the nutrient foramina, communication between the epiphyseo-metaphyseal and diaphyseal networks) and of the short bones, in the adult and the child, before the closing of the growth plate. The general organization of arterial vascularization of the hand and the wrist is pointed out, with the current nomenclature and the contribution of the recent publications, in particular in these, which relate to the distal extremity of the radius. The vascularization of each bone (radius and ulna, carpal bones, metacarpals and phalanges) is then described; making way, the anatomical bases of each vascularized bone graft, which can be harvested there, are described. The last technical projections are included, in particular the realization of the reverse flow vascularized bone grafts harvested from the metacarpals. This article still gives a progress report on the osseous vascularization of the short bones, in particular of those which are exposed the most to the osteonecrosis (scaphoid, lunatum). It has the ambition to light the reader and to prepare him (her) with the reading of the following chapters.     

Anatomie vasculaire osseuse à la main et au poignet

The design and the realization of vascularized osseous grafts at the hand and the wrist require a precise knowledge of the general and regional anatomy. This article gives first a progress report on current knowledge about the general organization of arterial and venous vascularization, of the long bones (number and localization of the nutrient foramina, communication between the epiphyseo-metaphyseal and diaphyseal networks) and of the short bones, in the adult and the child, before the closing of the growth plate. The general organization of arterial vascularization of the hand and the wrist is pointed out, with the current nomenclature and the contribution of the recent publications, in particular in these, which relate to the distal extremity of the radius. The vascularization of each bone (radius and ulna, carpal bones, metacarpals and phalanges) is then described; making way, the anatomical bases of each vascularized bone graft, which can be harvested there, are described. The last technical projections are included, in particular the realization of the reverse flow vascularized bone grafts harvested from the metacarpals. This article still gives a progress report on the osseous vascularization of the short bones, in particular of those which are exposed the most to the osteonecrosis (scaphoid, lunatum). It has the ambition to light the reader and to prepare him (her) with the reading of the following chapters.     

髂骨皮瓣修复手掌部毁损伤

目的 探讨应用吻合旋髂深动脉的髂骨皮瓣一期修复手掌部毁损伤所致多根掌骨复合组织缺损的疗效.方法 1996年以来,对8例手掌部毁损伤所致多根掌骨复合组织缺损,采用吻合旋髂深动脉的髂骨皮瓣重建手掌,并一期修复肌腱、神经.其中2根掌骨缺损3例,3根3例,4根2例.6例肌腱、神经缺损在2～3cm以内,通过短缩植骨,获得肌腱、神经的直接缝合;1例2～5掌骨缺损通过一期"y"形截骨,增加骨承载面,减小了骨瓣切取宽度;1例通过传统骨移植单独重建第一掌骨.获得了拇指单独活动功能;2例合并掌骨头缺损者一期行掌指关节成形术.结果 8例骨皮瓣全部存活.7例伤口 I期愈合,1例因术后皮瓣肿胀,拆除部分缝线,获得Ⅱ期愈合.术后随访1～3年.临床骨愈合时间为3～5周,全部获得骨性愈合.供区无明显并发症.术后手功能评定:优1例,良5例,可1例,差1例;优良率为75%.结论 应用吻合旋髂深动脉的髂骨皮瓣移植重建手掌,并一期修复肌腱和神经,可以较好地恢复手的外形和功能,是手掌毁损伤修复重建的一种有效治疗方法.     

Arthroplasty of the elbow joint using vascularized iliac bone graft for reconstruction of massive bone defect of the distal humerus

The authors present a case of a 39-year-old man with an enormous bone defect of the distal humerus secondary to an infected nonunion, who was successfully reconstructed using a vascularized iliac bone graft. The use of a vascularized iliac bone graft may be an option for reconstructing such massive defects of the metaphyseal area of the humerus.     

The mechanism of the carpal joint

The morphologic features of the carpal bones and their contacts play a highly significant role in the mechanism of the wrist joint. Displacements of the proximal carpal bones in both flexion and deviation of the hand take place in longitudinal articulation chains that are linked one to another. This concept is supported by the following observations: differences in curvature between the facets of the proximal carpals at the radiocarpal level suggest that simultaneous movements occur at the midcarpal level; the position of the proximal carpal bones is determined by their position with respect to both the distal carpal bones and the radius; displacements of the proximal carpal bones to the distal carpals result in swerving motions in the transverse plane in addition to dorsopalmar rotation (as a result, the volar rotated position of a proximal carpal in the volar flexed hand will differ from its position in the radial deviated hand and the positions of the proximal carpals in the dorsiflexed hand will differ from these in the ulnar deviated hand); and the three articulation chains, radial, central, and ulnar, cannot function on their own, since the linkage in the longitudinal direction is associated to a transverse linkage by the mutual joint contacts between the chains and by ligamentous interconnections.     

The carpal joint. Anatomy and function

The carpal joint can be approached as a mechanism consisting of kinematic chains. In these chains, the proximal carpals function as intercalated segments. Intercarpal displacements are linked to one another and are based upon the mutual attuning of carpal bone geometry, joint contacts, and ligamentous interconnections.     

Vascularized bone grafts for upper limb reconstruction: defects at the distal radius, wrist, and hand

Vascularized bone grafts have been successfully applied for the reconstruction of bone defects at the forearm, distal radius, carpus, and hand. Vascularized bone grafts are most commonly used in revision cases in which other approaches have failed. Vascularized bone grafts can be obtained from a variety of donor sites, including the fibula, the iliac crest, the distal radius (corticocancellous segments and vascularized periosteum), the metacarpals and metatarsals, and the medial femoral condyle (corticoperiosteal flaps). Their vascularity is preserved as either pedicled autografts or free flaps to carry the optimum biological potential to enhance union. The grafts can also be transferred as composite tissue flaps to reconstruct compound tissue defects. Selection of the most appropriate donor flap site is multifactorial. Considerations include size matching between donor and defect, the structural characteristics of the graft, the mechanical demands of the defect, proximity to the donor area, the need for an anastomosis, the duration of the procedure, and the donor site morbidity. This article focuses on defects of the distal radius, the wrist, and the hand.