游离带肌腱的尺动脉腕上掌侧穿支皮瓣修复指背复合组织缺损临床研究

发布时间：2019-06-04 10:18

【摘要】：背景：自上世纪80年代以来,穿支皮瓣得到较大的发展,在1988年Becker报道了尺动脉腕上皮支皮瓣在临床上的应用,1989年国内张高孟等在解剖学研究基础上,将尺动脉腕上皮支皮瓣应用于临床修复手部皮肤软组织缺损创面。尺动脉腕上支皮瓣修复手部皮肤软组织缺损从带蒂皮瓣转移发展到游离移植,获得了良好的效果。章文锋等于2011年报道了带肌腱的游离尺动脉腕上皮支上行支皮瓣修复手指软组织缺损。结合目前手外伤引起的指背皮肤合并伸指肌腱缺损的修复主要以单纯取掌长肌腱等肌腱移植修复伸指肌腱,以近节指背、掌骨背岛状皮瓣或邻指皮瓣等转位修复皮肤软组织缺损,供区需再取腹部或上臂全厚皮片游离移植,势必需要有3个供区来完成修复。显然如果用带部分尺侧屈腕肌腱的尺动脉腕上掌侧穿支皮瓣来修复指背复合组织缺损,只要一个供区就完成了肌腱和皮肤缺损的覆盖,极大的减少了供区的损伤和破坏。目的：本课题通过对25例26指临床病例进行6个月-2年的跟踪随访,总结该皮瓣的存活情况、外观、感觉恢复及肌腱愈合情况和指体的伸屈功能等,进一步总结游离带肌腱的尺动脉腕上掌侧穿支皮瓣修复指背皮肤肌腱缺损的临床应用经验,为该复合皮瓣在指背皮肤软组织合并伸指肌腱缺损的推广应用提供临床支持,为解决手部复合组织缺损修复提供优良的皮瓣覆盖技术。方法：临床上在2008年1月至2013年12月对于25例26指指背皮肤软组织合并伸指肌腱缺损患者,以患肢同侧带部分尺侧屈腕肌腱的尺动脉腕上掌侧穿支皮瓣对指背皮肤肌腱缺损进行游离移植,术中带浅层1/2厚度的尺侧屈腕肌腱长约2.0～5.5cm,并借腱膜保留在皮瓣内不分离,保持移植肌腱的血供。术中进行临床显微解剖,进一步总结该穿支的特点。术后1周内观察该皮瓣的存活规律,动静脉危象发生情况及处理方法原则。术后3周、1.5个月、3个月、6个月、1年、2年进行随访,观察该供受区的外观以及患指的伸屈功能,总结该皮瓣的临床应用特点与经验。结果：临床上25例26指中24指皮瓣成活,随访0.5～2年时间,皮瓣不臃肿,修复神经者感觉恢复S3～S3+级。1指出现动脉危象,经手术探查后成活；3指出现水泡、发紫,其中1指经拆线处理后成活,1指部分坏死,经换药后疤痕愈合,1指完全坏死,二期予植皮术。随访6-24个月,皮瓣色泽与受区相似,无明显臃肿,患指伸屈指恢复正常或接近正常。腕部供皮区疤痕挛缩不明显,腕关节活动及屈腕肌腱肌力无影响。结论：尺动脉在腕上掌侧有恒定的皮肤穿支,可用穿支数量1-3条不等,满足设计要求,且该部位的皮肤与指背的皮肤质地相近,可行单一肢体麻醉,单一手术野完成,一个供区即完成2个组织的缺损修复,患者容易接受。游离腕上穿支皮瓣移植术后供区往往可直接缝合,供受区外观良好,屈腕功能无影响。因此,对于中小面积指背皮肤软组织复合伸指肌腱缺损,游离带肌腱的尺动脉腕上穿支皮瓣修复指背皮肤肌腱缺损是一个不错的选择,值得临床推广应用。
[Abstract]:Background: Since the 1980 's, the perforator flap has been developed. In 1988, Becker reported the clinical application of the cutaneous branch of the ulnar artery of the ulnar artery. The application of the skin flap of the ulnar artery to the soft tissue defect of the hand skin The upper branch of the ulnar artery of the ulnar artery was used to repair the soft tissue defect of the hand skin from the pedicled skin flap to the free graft, and a good effect was obtained. The results showed that the upper branch of the upper branch of the free ulnar artery with the tendon was reported in 2011 to repair the soft tissue of the finger. The repair of the finger-back skin combined with the present hand injury refers to the repair of the tendon defect by simply taking the tendon of the palmar tendon and the like, and repairing the soft tissue defect of the skin by the transposition of the near-node finger, the dorsal metacarpal island-shaped skin flap or the adjacent finger flap. It is necessary to take the full thickness of the abdomen or the upper arm for free transplantation, and there will be three supply areas to complete the repair. It is clear that if the dorsal metacarpal side of the ulnar nerve of the flexor tendon of the ulnar side of the ulnar nerve is used to repair the defect of the dorsal composite tissue, only one donor area can complete the covering of the tendon and the skin defect, which greatly reduces the damage and the rupture of the donor area. Bad. Objective: To follow up the follow-up of 6-2-year follow-up of 25 cases with 26 finger clinical cases, and summarize the survival condition, appearance, sensory recovery and tendon healing condition and finger body of the skin flap. To further sum up the clinical application experience of the free-band tendon in the repair of the tendon defect of the dorsal skin, the application of the composite skin flap to the reconstruction of the soft tissue of the dorsal skin and the extension of the tendon defect is further summarized. Is used for clinical support, and provides excellent skin for solving the defect repair of the hand composite tissue defect. valve cover Methods: From Jan.2008 to December,2013,25 cases of finger dorsal skin soft tissue combined with extensor tendon defect were used to treat the dorsal skin of the finger with a branch of the ulnar side of the ulnar-side flexor tendon of the same ipsilateral band of the affected limb. The tendon defect was free to graft, and the length of the ulnar flexor tendon with a superficial layer of 1/2 in the operation was about 2.0-5.5cm, and the tendon membrane was retained in the skin flap without separation. The blood supply of the grafted tendon was maintained. The clinical microdissection was performed during the operation. The characteristics of the perforator were summarized in this step. The survival of the skin flap was observed within one week after the operation, and the arteriovenous crisis occurred. The conditions and treatment methods were followed. The follow-up was carried out for 3 weeks, 1.5 months,3 months,6 months,1 year and 2 years after operation, and the appearance of the area and the flexion function of the affected finger were observed, and the skin flap was summarized. Clinical The results were as follows:24 of the 26 fingers in the clinical study were survived, the time of follow-up was 0.5 ~ 2 years, the skin flap was not bloated, and the restoration of the nerve to the S3 ~ S3 + grade. survival;3 refers to the occurrence of blisters and purple, wherein 1 refers to survival after the removal of the line,1 refers to partial necrosis, and after the drug is changed, the scar is healed, 1. Complete necrosis, phase II to skin grafting. Follow-up for 6-24 months. The color and color of the skin flap is similar to that of the affected area. The finger extension is normal or close to normal. The scar contracture in the skin area of the wrist is not obvious, and the wrist is closed. joint activity There is no effect on the muscle strength of the flexor tendon of the wrist. Conclusion: The ulnar artery has a constant skin penetration on the palm side of the wrist. It can be used for the design requirements. The skin of this part is similar to that of the skin of the finger. And the single operation field is completed, and one supply area is finished. In the case of defect repair of 2 tissues, the patient was easily accepted. In addition, there was no effect on the appearance of the affected area and the function of the flexion and wrist. Therefore, for the soft tissue of the soft tissue of the dorsal skin of the medium and small area, the defect of the tendon and the ulnar artery of the free-band tendon were used to repair the tendon defect of the dorsal skin.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R658.2

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