足趾移植拇指与手指再造的临床研究

目的探讨足趾移植拇指与手指再造的方法和疗效。方法采用部分坶趾移植拇指部分再造22例,躅甲瓣或带足背皮瓣船甲瓣移植拇指再造13例,第2足趾移植再造拇指4例,再造手指3例,及带足背皮瓣的第2足趾移植再造拇指7例,带足背皮瓣的第2,3足趾移植再造手指7例,带足背皮瓣的躅甲瓣或第2趾和第2,3趾组合移植再造拇手指10例,双足第2足趾移植全手缺失二指再造2例,共68例97指。结果再造拇手指和皮瓣全部成活,成活率为100％,术后经3月～10年的随访和信访,按中华医学会手外科学会拇、手指再造功能评定试用标准评定：优62指,良24指,可9指,差2指,优良率达88．66％。结论采用部棚趾、第2足趾棚甲瓣移植再造拇手指,带足背皮瓣的躅甲瓣、第2趾或第2,3趾组合移植行合并手部皮肤缺损的拇手指再造,效果满意。     

Reconstruction of Composite Soft Tissue Defect in the Distal Finger Using Partial Toenail Flap Transfer

Objective

Composite tissue loss involving the distal finger pulp and the nail is a common but challenging finger injury to restore. This study introduces a reconstruction procedure for a distal finger pulp and nail defect using a partial toenail flap transfer.

Methods

Twenty digits, including 16 thumbs, two index fingers, and two middle fingers, with composite soft tissue defects were treated with a partial toenail flap transfer from October 2015 to January 2020. Shortening revision of the great toe phalanx, a V-Y advancement flap of the toe pulp, and a local pedicle flap from a second toe transfer were used to cover the donor sites, and no skin grafts were required. Functionality was evaluated using the validated Spanish version of the Quick-DASH scale. The aesthetics of both the reconstructed and donor sites were evaluated using the Vancouver Scar Scale (VSS). The static two-point discrimination (2-PD) of the finger pulp was used as a measure of tactile agnosia.

Results

All donor site wounds healed well. The average follow-up time was 23.6 months (6–39 months). The mean Quick-DASH functional score was 7.1. The VSS scores were 4.02 ± 0.29 and 4.00 ± 0.38 for the reconstructed and donor sites, respectively. The static 2-PD of finger pulp was 4.5 ± 0.76 mm. The patients were satisfied with finger motion, sensory function, and aesthetic contour.

Conclusions

Partial toenail flap transfer is the recommended treatment to regain motion, sensation, function, and a satisfactory aesthetic appearance when considering repairing a composite soft tissue distal finger defect with accompanying loss of the perionychium, particularly in the thumb, index finger, or middle finger.     

拇指末节部分缺损的再造与修复

目的报道采用不同类型的趾部分组织移植再造与修复拇指末节部分缺损的临床效果。方法应用吻合血管的趾腹皮瓣、趾甲瓣、甲皮瓣、带部分末节趾骨的甲瓣及趾腓侧半复合组织瓣游离移植分别再造与修复五种类型的拇指末节部分缺损27例。结果手术全部获得成功,经半年～5年(平均2.1年)随访,再造拇指指间关节活动度平均为52°,指腹两点分辨觉为5～8mm,外形良好。结论以趾为供区的不同类型组织瓣游离移植是再造与修复拇指末节部分缺损的最佳方法。     

示指背侧皮瓣与趾腓侧皮瓣瓦合修复拇指套脱伤

目的 介绍应用示指背侧岛状皮瓣与游离趾腓侧皮瓣瓦合修复拇指套脱伤的临床方法.方法 对9例残留甲床的拇指套脱伤患者,采用示指背侧岛状皮瓣与趾腓侧游离皮瓣瓦合进行修复.结果 术后9例拇指瓦合皮瓣全部存活,随访时间为6个月至3年,皮瓣颜色、质地良好,拇指指甲生长良好,外形和功能满意,皮瓣两点分辨觉为8～10mm.供区示指及足趾植皮区愈合良好,无明显功能影响.结论 示指背侧岛状皮瓣与游离趾腓侧皮瓣瓦合修复是治疗残留甲床的拇指套脱伤的一种较好方法.     

逆行第一跖背动脉岛状皮瓣修复(足母)趾腓侧游离皮瓣供区创面

目的应用逆行第1跖背动脉岛状皮瓣修复趾腓侧游离皮瓣的供区,为减少显微外科供区损伤提供新方法。方法2000年2月至2004年6月,对12例拇指及其他手指软组织缺损,采用趾腓侧游离皮瓣移植修复。根据第1跖背动脉和跖底动脉在跖趾关节处存在恒定的交通支的解剖学基础,切取逆行第1跖背动脉岛状皮瓣修复趾供区创面,足背供区直接缝合。结果12例趾腓侧游离皮瓣和逆行第1跖背动脉岛状皮瓣移植全部成活,平均随访10个月,皮瓣外观和功能恢复良好。趾腓侧游离皮瓣平均两点辨别觉为6mm,逆行第1跖背动脉皮瓣为10mm。结论在趾腓侧游离皮瓣移植修复拇指或其他手指软组织损伤的同时,应用逆行第1跖背动脉岛状皮瓣完善修复趾供区创面,达到了＂双赢＂的手术目的。     

带足背趾蹼皮瓣的双足三趾移植修复手毁损伤

目的探讨修复全手毁损伤的术式及效果。方法本组29例,男22例,女7例。年龄15～31岁。所有患者均从腕部以远皮肤缺损,皮肤挫伤严重,伴有不同程度的掌指骨骨折,皮肤缺损18cm×8cm～22cm×10cm。切取双侧足背、口止母趾近节腓侧、趾蹼皮瓣的双足3趾游离移植修复手毁损伤,其中双侧足背皮瓣修复手掌和手背创面,双侧口止母趾近节腓侧和趾蹼皮瓣重建虎口,双足3趾再造拇指和2个手指。共切取右足23个皮瓣46个足趾,左足6个皮瓣,修复23只右手和6只左手。结果本组58个复合皮瓣,再造拇指29个,手指58个。经1～8年随访,再造手29例87个拇手指全部成活,手外形及功能恢复良好。结论术式最大限度地保留了伤手的残留功能,再造手对指稳定性好,能满足手部活动需要,值得推广应用。     

The aesthetic mini wrap-around technique for thumb reconstruction

In the past 12 years, 16 thumb defects at, or distal to, the interphalangeal joint were reconstructed using a great toe mini wrap-around flap. A flap including the entire nail and most of the distal phalanx of the great toe was used. Fifteen of the grafts survived. The sensory recovery of the reconstructed thumb was good as assessed by 2-point discrimination test with an average of 10 mm (range 5-15), and there were no complaints of cold intolerance. This technique results in good cosmetic appearance, and all patients were pleased with the cosmetic aspect of the thumb and there was no significant morbidity at the great toe donor site. The final decision to reconstruct a distal thumb amputation is influenced by gender, job, and age of the patients. The great toe mini wrap-around flap is an excellent reconstruction technique in selected patients.     

游离膝上外皮瓣移植覆盖(足母)甲皮瓣切除后的创面

目的探讨拇甲皮瓣带足背皮瓣切取后，供区创面应用游离膝上外皮瓣移植覆盖的手术效果。方法2003年4月-20Q5年12月，我院对8例拇指大面积套状撕脱伤的患者，在进行游离拇甲皮瓣带足背皮瓣移植再造拇指的同时，再应用游离膝上外皮瓣移植覆盖足背供区的创面。结果术后再造拇指全部存活，覆盖足部供区的皮瓣全部存活。术后随访时间为6-18个月，再造拇指外形和功能良好，指腹两点分辨觉为6．8mm。供区拇趾保留全部长度，并有跖屈和背伸功能，但皮瓣较臃肿，其中4例行皮瓣修整术。供足及膝部行走、跑步均无疼痛。6例足功能分析显示，动态、静态足底应力分布与对侧十分接近，步态正常。结论利用游离膝上外皮瓣移植覆盖足背供区创面，能够很好地保留供足的功能。该方法尤其适用于拇指皮肤缺损较多，采用蹰甲皮瓣移植再造时需扩大切取足背皮瓣供区创面的患者。     

足部皮瓣移植修复拇、手指皮肤缺损

目的 探讨应用5种足部皮瓣移植修复拇、手指皮肤缺损的疗效。方法 1987年5月-2003年6月，对93例拇、手指皮肤缺损的患者，采用5种不同类型的足部皮瓣进行移植修复。其中采用趾腹皮瓣移植修复指腹缺损27例；趾甲瓣移植修复指甲与指背皮肤缺损8例；[足母]甲瓣或第二趾趾甲皮瓣移植修复拇、手指皮肤脱套伤48例；[足母]趾腓侧半月形皮瓣移植修复拇、手指近节与（或）中节皮肤环形缺损6例；足背三叶或二叶皮瓣移植修复2～3个手指部分皮肤缺损4例。结果 术后皮瓣成功90例，失败3例，成功率为96．8％。供区3例[足母]甲瓣切取后创面不愈．经扩创、植皮后愈合。术后随访8个月～6年．平均2年，皮瓣质地、弹性及拇、手指外形功能良好．指腹皮瓣两点分辨觉达5～8mm。供区行走无影响。结论 选择不同类型的足部皮瓣游离移植是修复拇、手指不同部位皮肤缺损的理想、有效的治疗方法。     

Nail flaps for microsurgical aesthetic reconstruction of thumb and donor site of great toe

Abstract

We describe a case of mutual transpositional transfers of toe and thumb in an attempt to restore the aesthetic appearance of the thumb with a deformity of the nail. The reconstructed thumb with the skin-nail flap from the great toe gave an excellent result both aesthetically and functionally, and the nail grew normally. The donor site of the great toe that was covered with the skin-nail flap from the thumb healed satisfactorily. This is another option for donor site management, the results of which are good, but the indications are under discussion.     

应用改良(躅)甲瓣修复拇手指脱套伤

目的 探讨应用改良(躅)甲瓣修复各型拇、手指脱套伤的临床疗效.方法 根据不同损伤类型,采取4种方式修复18例28个脱套拇手指:①单侧改良(躅)甲瓣修复9例9个拇指近节中段以远脱套及3例3指近侧指间关节以远脱套;②单侧改良(躅)甲瓣加第二趾胫侧皮瓣修复2例2指全指脱套;③双侧改良(躅)甲瓣修复1例双侧拇指脱套;④双侧改良(躅)甲瓣加第二趾胫侧皮瓣与带感觉的超薄股前外侧皮瓣修复3例12指脱套.(躅)甲瓣切取时携带全部趾甲,保留(躅)趾趾底偏胫侧三角形皮瓣.结果 18例22块(躅)甲瓣及3块超薄股前外侧皮瓣均一期完全成活.15例获随访8～25个月,再造拇、手指外观接近健侧指体,运动及感觉恢复满意,供区无增生性瘢痕,跖底三角形皮瓣显著增宽,所有患者步行、跑、跳均无明显受限.结论 应用改良(躅)甲瓣修复拇手指脱套伤,不但受区可以获得接近健侧的良好外观和功能,而且可使供区损伤减少到最低限度,是目前显微重建拇、手指脱套伤的最佳术式之一.     

Combined great toe dorsal nail-skin flap and medial plantar flap for one-stage reconstruction of degloved finger

BackgroundHistorically, the degloved finger with the total loss of nail and skin had been resurfaced with an expanded great toe wrap-around flap transfer for better outcomes. The purpose of this study aims to present our experience with a related modified design, with total preservation of a weight-bearing plantar skin.MethodFrom April 2016 to September 2019, nine fingers (5 index and 4 middle fingers) in nine cases, with skin loss to the base of the proximal phalangeal or metacarpophalangeal (MCP) joint level, were reconstructed with combined great toe dorsal nail-skin flap and medial plantar artery perforator (MPAP) flap. The dorsal great toe donor was covered with a thin groin flap, and the medial plantar site was covered with a full-thickness skin graft. The cutaneous nerves were preserved within both flaps. Standardized assessment of outcome in terms of sensory, functional, and esthetic performance of the reconstructed fingers was completed.ResultsFlap survival was achieved in all cases. The contour of the reconstructed digits was comparable with the contralateral one. The fingers were available for a mean follow-up of 28 months (ranged, 22-39 months). The mean dimension of the great toe dorsal nail-skin flap was 8.5 × 4.0 cm (ranged, 6.5 × 3.5-11.0 × 4.5 cm). The average size of the MPAP flap was 6.5 × 4.5 cm (ranged, 5.0 × 3.5-8.0 × 5.5 cm). At the last follow-up, the functional and aesthetic consequences were satisfactory, as well as the restored sensory.ConclusionReconstruction of degloved fingers with the great toe dorsal nail-skin flap combined MPAP flap, preserving a plantar weight-bearing area, results in excellent contour and functional outcome. Donor-site morbidity in the foot was minimal.     

拇指末节半侧缺损的重建

目的探索重建拇指末节半侧缺损的理想术式——趾腓侧部分趾甲瓣移植。方法取对侧趾腓侧部分趾甲瓣重建拇指末节桡半侧缺损，同侧趾腓侧部分趾甲瓣重建拇指末节尺侧缺损。吻合趾－指动静脉以重建血循环。结果临床应用３例均获成功。术后随访３～６年，指甲对合、生长良好，外形满意；重建的末节半侧均有出汗，两点辨别觉为４～６ｍｍ，患者均已恢复工作。结论采用吻合趾－指动静脉的趾腓侧部分趾甲瓣重建拇指末节半侧缺损，是一种比较理想的手术方法。     

Nail flaps for microsurgical aesthetic reconstruction of thumb and donor site of great toe

Abstract We describe a case of mutual transpositional transfers of toe and thumb in an attempt to restore the aesthetic appearance of the thumb with a deformity of the nail. The reconstructed thumb with the skin-nail flap from the great toe gave an excellent result both aesthetically and functionally, and the nail grew normally. The donor site of the great toe that was covered with the skin-nail flap from the thumb healed satisfactorily. This is another option for donor site management, the results of which are good, but the indications are under discussion.     

Digital reconstruction and donor site resurfacing: a two-flap technique

Use of a great toe pulp flap is one of the methods to repair partial soft-tissue defect of the thumb or other digits. However, the conventional application of free skin grafts to close the donor site may bring donor-site morbidity. The authors present a two-flap technique that a reverse first dorsal metatarsal artery (FDMA) flap resurfaces the defect of the free great toe pulp flap. Six patients with soft-tissue defects of the thumbs or fingers were treated with this technique. Both the pulp and reverse flaps survived uneventfully after reconstruction of the thumbs and fingers. The reverse flap to resurface the donor site on the great toe was sensate and durable. Satisfactory appearance and function were gained in all patients. Results revealed that this technique can be accepted as an alternative method when treating soft tissue defect of the thumb or finger.     

足拇趾甲瓣与第2趾趾骨皮瓣组合再造拇指术

目的探讨应用足拇趾甲瓣与足第2趾趾骨皮瓣组合再造拇指的临床应用价值。方法12例（13指）拇指缺损平面：Ⅰ度缺损3例3指,Ⅱ度缺损5例6指,Ⅲ度缺损2例2指,Ⅳ度缺损1例1指,Ⅴ度缺损1例1指。依据手指缺损的长度和范围设计拇趾趾甲瓣与第2足趾趾骨皮瓣切取范围,第2趾携带胫侧皮瓣。末节再造者8例9指,其拇趾供区全厚植皮,第2趾创面直接闭合;4例4指应用第2趾甲皮瓣修复拇趾趾创面。结果12例均获随访,时间28个月。再造指全部成活12指,甲床部分坏死1指。再造指感觉运动功能及外观功能满意。按赵书强手功能评定标准：优3例,良9指,可1指。足供区外观功能均满意。结论足拇趾甲瓣与第2趾趾骨皮瓣组合再造术是解决拇手指缺损的有效方法。     

指端缺损的显微外科修复

目的 探讨手指远端各种缺损的修复方法. 方法 采用第二足趾趾动脉旋转"三叶皮瓣"修饰性再造23指:用(拇)甲瓣、半(拇)甲瓣、(拇)趾与第二足趾组织瓦合修复拇手指脱套伤33指;用(拇)趾腓侧及第二足趾胫侧皮瓣修复指腹缺损28指;(拇)趾趾甲或近侧带部分皮瓣修复指甲皮肤缺损27指.结果 临床修复98例111指,除5例出现血管危象,及时处理后恢复外,其它均一期成活,外形美观.结论 用显微外科技术修复拇手指远端的缺损,是理想的方法,达到了缺什么、补什么的理想目的 .     

自体趾尖部分移植再造手指指尖

目的 探讨自体(砪)趾尖部分移植再造手指指尖的手术方法.方法 2002年8月-2008年1月,以自体(砪)趾尖为供体,于其腓侧设计与缺损的手指指尖大小相同的部分趾尖,游离切取塑形后移植再造手指指尖.再造手指指尖32例32指,其中拇指指尖11例,示指指尖13例,中指指尖8例.急诊再造11例,择期再造21例.供区创面直接缝合.结果 本组32例全部存活,其中1例右示指指尖再造术后14 h出现静脉危象,手术探查后存活.27例于术后3～8个月内行整形术.随访29例,失访3例,随访时间为8～26个月,再造指尖外形接近健侧指尖,手指功能及两点分辨觉同健指.结论 自体(砪)趾尖部分移植再造手指指尖外形逼真,功能完善;供区无需植皮,供趾趾尖结构、外形、功能无改变,仅体积缩小.     

自体趾尖部分移植再造手指指尖

目的 探讨自体(砪)趾尖部分移植再造手指指尖的手术方法.方法 2002年8月-2008年1月,以自体(砪)趾尖为供体,于其腓侧设计与缺损的手指指尖大小相同的部分趾尖,游离切取塑形后移植再造手指指尖.再造手指指尖32例32指,其中拇指指尖11例,示指指尖13例,中指指尖8例.急诊再造11例,择期再造21例.供区创面直接缝合.结果 本组32例全部存活,其中1例右示指指尖再造术后14 h出现静脉危象,手术探查后存活.27例于术后3～8个月内行整形术.随访29例,失访3例,随访时间为8～26个月,再造指尖外形接近健侧指尖,手指功能及两点分辨觉同健指.结论 自体(砪)趾尖部分移植再造手指指尖外形逼真,功能完善;供区无需植皮,供趾趾尖结构、外形、功能无改变,仅体积缩小.     

自体趾尖部分移植再造手指指尖

目的 探讨自体(砪)趾尖部分移植再造手指指尖的手术方法.方法 2002年8月-2008年1月,以自体(砪)趾尖为供体,于其腓侧设计与缺损的手指指尖大小相同的部分趾尖,游离切取塑形后移植再造手指指尖.再造手指指尖32例32指,其中拇指指尖11例,示指指尖13例,中指指尖8例.急诊再造11例,择期再造21例.供区创面直接缝合.结果 本组32例全部存活,其中1例右示指指尖再造术后14 h出现静脉危象,手术探查后存活.27例于术后3～8个月内行整形术.随访29例,失访3例,随访时间为8～26个月,再造指尖外形接近健侧指尖,手指功能及两点分辨觉同健指.结论 自体(砪)趾尖部分移植再造手指指尖外形逼真,功能完善;供区无需植皮,供趾趾尖结构、外形、功能无改变,仅体积缩小.