摘要
目的:对虎口中重度挛缩患者行拇指背侧筋膜皮瓣修复,并观察术后患侧中远期的功能恢复情况。方法:选取1995-08/2004-12广东省中医院珠海医院骨科收治的13例重度虎口挛缩患者,均采用带拇指背侧筋膜皮瓣转移修复,术前常规检查确定是否有手术禁忌证。手术于臂丛麻醉下进行,切取拇指背侧筋膜皮瓣(带拇背桡侧或尺侧动脉及神经),皮瓣切取范围远端至拇指甲根部近侧0.5cm,两侧至指侧中线,以第一掌骨基底部至第一掌骨中点之间为蒂部。供区创面予以植皮,皮瓣转移后首先修复虎口底部,如掌侧或两侧遗留少许创面,可以游离皮片进行移植修复。对掌功能位行克氏针固定三四周,拔针早期中药熏洗,术后半年内虎口必须予以支具保护,以保证修复后效果。按照手指总活动度系统评价法(优:正常;良:手指总活动度为健侧的75%以上;尚可:手指总活动度为健侧的50%～75%;差:手指总活动度为健侧的50%以下;极差:手指总活动度比术前恶化)以及患侧外形、感觉、拇指使用情况等对关节功能进行综合评估。结果:实验纳入13例患者均完成2年随访,中途无脱落者。①术后不同随访时间患侧关节功能恢复情况:13例患者术后6个月皮瓣成活良好,虎口开大与健侧基本相同,关节外形满意,关节稳定,术后2年屈曲畸形消失,伸指活动可,拇指外展对掌功能良好,第1掌指关节活动正常,主观满意率为84.6%(11/13)。②术后6个月手指总活动度评估结果:13例患者中,优10例,良2例,可1例,优良率92.3%。③术后6个月患侧外形、感觉及拇指使用情况:全部患者重建虎口外形正常,皮肤质地及色泽接近正常,未见明显的色素沉着,冬季皮肤无明显异常;13例患者痛觉全部恢复,触觉迟钝者占6.2%,只有17.4%的患者两点辨别感觉恢复到正常范围内,实体综合感觉能力优良率92.1%,平均分13分;全部患者在工作和生活中均能自然地使用患指,使用时虎口无触痛或感觉异常等现象。结论:虎口中重度挛缩患者行拇指背侧筋膜皮瓣修复,重建虎口外形美观,感觉良好,拇指外展及对掌功能恢复满意,损伤小,皮瓣切取范围完全可以达到虎口开大后所需皮瓣修复的宽度,手术操作简便易行,其中远期疗效满意。
AIM： The plerosis of dorsal fascial flap of thumb was conducted in patients with moderate and severe thumb web contracture, and to explore the functional restoration of medium-term and long-term injured sidedness after operation. METHODS： Thirteen patients with severe thumb web contracture, who were treated in the Department of Orthopedics, Zhuhai Hospital, Guangdong Hospital of Traditional Chinese Medicine from August 1995 to December 2004, were selected, and were repaired with dorsal fascial flap transfer plerosis of thumb, and before the operation, they were checked with routine examination to define having the operation abstinence or not. The operation was performed under the narcosis of the brachial plexus. The fascial flap of the dorsal thumb was cut （including the dorsal thumb radialis or ulnaris artery and nerve）. The area of the flap cutting was from distance of 0.5 cm of thumbnail base to nail mot of thumb, from the two sides to the middle line of the thumbnail lateral. The rotative point was from the first metacarpal bone to the middle point of the first metacarpal. The injured face of the donor site was transplanted of the skin. After the transfer of the flap, firstly the bottom of the web was repaired. If there were some injured surface left at the palm side or the two sides, the free skin graft could be freed to perform transplantation plerosis. The Kirschner wire was performed on the palm functional position fixing about three or four weeks. The traditional Chinese medicine was used to smoke and wash the position at the early period of plucking needles. The web must be protected by brace within half a year after operation in order to keep the effect after plerosis. According to the general activity system evaluation method （excellent： normal; good： the general activity of the finger was over 75% of the uninjured side; so-so： the general activity of the finger was 50%-75% of the uninjured side; Bad： the general activity of the finger was less than 50% of the uninjured side; real bad： the general activity of the finger was worse than that before） and outline form, sensation and the usage condition of thumb of the injured side etc. evaluated synthetically the joint function. RESULTS： All of the 13 patients involved in the experiment were done the 2-year follow-up, without drop. ①The joint functional restoration condition of the injured side during different follow-up time after operation： The flap sensation was good grown at 6 months after operation of the 13 patients. The expanding range of the web was similar to the uninjured side. The appearance of joint was satisfactory, stable. The flexion deformity was disappeared at 2 years after operation with extended fingers activities. The thumb extension and opposition function were good, and the finger joint motion of the first metacarpal was normal with 84.6% （11/13） subjective satisfaction rate. ②The evaluation of the general activity of the fingers at 6 months after operation： Among the 13 patients, there were 10 patients for excellence, 2 patients for good, and 1 patient for so-so, and the excellent and good rate was 92.3%.③The outline, sensation of the injured side and the usage of thumb： The outline form of the reconstructed web of all the patients was normal, and the quality nature and the color luster of the skin was near to normal. There were no pigmen deposition, and no significant abnormality of the skin in winter; The ache of the whole 13 patients was recovered, 6.2% of the patients with taction bluntness. Only 17.4% of the rate of sensation of discrimination between two points of the patients recovered to the normal range. The rate of excellent and good of the entity colligation sensation ability was 92.1%, averagely 13 points; All the patients could use the injured finger naturally in the work and living.There were no phenomena of tenderness or paraesthesia etc. when the web was used. CONCLUSION： The plerosis of in patients with moderate and dorsal fascial flap of thumb is conducted severe thumb web contracture. The reconstructed web has beautiful outlook with good sensation. The functional restoration of the thumb extenstion and opposition is satisfactory with small injury. The range of the cutting of the flap can reach the prosthetic width of the needed flap after the big open of the web. The operation is easy to perform with satisfactory long-term treatment effect.
出处
《中国临床康复》
CSCD
北大核心
2005年第30期20-21,共2页
Chinese Journal of Clinical Rehabilitation
