甲弧影以远弧形切口联合甲模板回植在治疗甲下血管球瘤中的应用

甲弧影以远弧形切口联合甲模板回植在治疗甲下血管球瘤中的应用

陈伟健刘彬鹿亮曾建学李多玉

本文来源：《中华整形外科杂志》2023年2月第39卷第2期

DOI:10. 3760 / cma.j.cn114453-20220726-00234

作者单位：中国科学技术大学附属第一医院（安徽省立医院）骨科，合肥230001

通信作者：鹿亮，Email: luliangzhwk@163.com

引用本文

陈伟健, 刘彬, 鹿亮, 等. 甲弧影以远弧形切口联合甲模板回植在治疗甲下血管球瘤中的应用 [J] . 中华整形外科杂志, 2023, 39(3) : 266-272. DOI: 10.3760/cma.j.cn114453-20220726-00234.

【摘要】

目的探讨采用甲弧影以远弧形切口联合甲模板回植治疗甲下血管球瘤的可行性及疗效。

方法回顾性分析2019年3月至2021年6月中国科学技术大学附属第一医院骨科治疗的甲下血管球瘤患者的临床资料。所有患者在拔除指甲后，采用甲弧影以远弧形切口入路切开甲床，暴露瘤体后完整切除，切开的甲床瓣原位复位，不予缝合，选择使用5 ml注射器针筒或原甲板制作甲模板，戳引流孔，回植覆盖于甲床表面，三点缝合加压固定，常规换药，3周后拆除甲模板。记录患者术前及术后1个月疼痛视觉模拟法(VAS)评分，并随访观察甲床愈合、疼痛改善、指甲生长及肿瘤复发等情况。手术前后VAS评分以M(Q1，Q3)表示，采用Mann-Whitney U检验进行分析，P<0.05为差异有统计学意义。

结果共纳入37例患者，男5例，女32例；年龄18~67岁，平均39岁。术后病理均确诊为甲下血管球瘤，所有患者均获得随访，随访时间6~36个月，平均22个月，术后换药均无明显痛感，拆除甲模板后见甲床平整干燥，无明显瘢痕形成，术后切口均一期愈合，新生指甲平整光滑、外观满意，疼痛症状均消失，随访期间无复发。术前VAS评分为5.0(4.5，6.0)分，术后1个月VAS评分为0.0(0.0，0.0)分，差异具有统计学意义(Z＝－7.57，P<0.001)。

结论甲弧影以远弧形切口治疗甲下血管球瘤，能有效保护甲床生发基质，瘤体暴露充分，可彻底切除，复发率低，同时结合甲模板回植可显著减轻甲床瘢痕形成，有效预防术后指甲畸形，方法简单，易于操作，临床疗效显著。

【关键词】血管球瘤；指甲；指甲疾病；甲床；甲弧影；甲模板

Application of distal arc-shaped incision of lunula combined with nail template replantation in the treatment of subungual glomus tumor

Chen Weijian, Liu Bin, Lu Liang, Zeng Jianxue, Li Duoyu

Department of Orthopedics, the First Affiliated Hospital of University of Science and Technology of China (Anhui Provincial Hospital), Hefei 230001, China

Corresponding author: Lu Liang, Email: luliangzhwk@163.com

【Abstract】

Objective To investigate the feasibility and efficacy of distal arc-shaped incision of lunula combined with nail template replantation for the treatment of subungual glomus tumor.

Methods The clinical data with subungual glomus tumor treated in the Department of Orthopedics of First Affiliated Hospital of the University of Science and Technology of China from March 2019 to June 2021 were retrospectively analyzed. Each patient removed the nail, the nail bed was cut into by a distal arc-shaped incision of the lunula. After the tumor was exposed, the tumor was resected completely, the nail bed flap was reduced in situ without suturing. The nail template was made by using the 5 ml syringe barrel or the original nail and poked the drainage holes in it, then the nail template was covered on the nail bed surface, three-point suturing and pressurized fixation, routine dressing change, and the nail template was removed 3 weeks after the procedure. The visual analogue scale (VAS) of pain was recorded preoperative and one month after the operation, and nail bed healing, pain improvement, nail growth, and tumor recurrence were observed. VAS scores before and after surgery were expressed as M(Q1, Q3), and analyzed by Mann-Whitney U test, P<0.05 was considered statistically significant.

Results A total of 37 patients were enrolled, including 5 males and 32 females. The age ranged from 18 to 67 years old, with an average of 39 years old. All patients were confirmed as subungual glomus tumors by postoperative pathology, they were followed up for 6 to 36 months, with an average of 22 months. All of the patients had no obvious pain during the dressing change, after removing the nail template, the nail bed was flat and dry, and no obvious scar formation was found. All postoperative incisions were healed in one stage, the new nail recovered smoothly with a satisfactory appearance, the pain symptoms disappeared completely, and also no recurrence occurred during follow-up. The preoperative VAS score was 5.0 (4.5, 6.0), the VAS score one month after the operation was 0.0 (0.0, 0.0), and the difference was statistically significant (Z=-7.57, P<0.001).

Conclusion The distal arc-shaped incision of the lunula for the treatment of subungual glomus tumor can effectively protect the germinal matrix of the nail bed, with sufficient tumor exposure, complete resection, and low recurrence rate. At the same time, combined with nail template replantation can significantly reduce nail bed scar formation and effectively prevent postoperative nail deformity. The method is simple, easy to operate, and has significant clinical efficacy.

【Key words】Glomus tumor; Nails；Nail Diseases；Nail bed; lunula; Nail template

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: Ethical approval was given by the Medical Ethics Committee of Anhui Provincial Hospital（2022-R-237）.

血管球瘤是发生于血管球的良性软组织肿瘤，可发生于全身多处，约75%发生在手部，尤以手指甲下最为常见[1,2,3,4]。长期的触痛和冷刺激的敏感性让患者饱受疼痛的折磨，常常给他们的生活和工作带来极大的困扰，而彻底的手术切除则是治疗甲下血管球瘤唯一有效的方法。目前常用的临床术式主要为2大类：经甲床入路与经甲床侧方入路[5]，各有优劣和相应的适应证。因此，如何在保证彻底切除瘤体降低复发的同时，尽可能地降低对甲床的损伤，避免术后新生甲板的畸形，成为近年来国、内外学者探讨的热点。自2019年，我们对甲下血管球瘤患者采用甲弧影以远弧形切口联合甲模板回植的方法治疗，取得了良好的效果。

资料与方法

一、资料选择

回顾性分析2019年3月至2021年6月，中国科学技术大学附属第一医院骨科收治的甲下血管球瘤患者的临床资料。纳入标准：(1)术前检查符合典型的临床表现三联征，即阵发性剧痛、难以忍受的触痛、疼痛的冷敏感性；(2)高频彩超提示指甲下可见明显实质性占位，伴或不伴有明显指骨压迫；(3)患者能够理解知情同意文件，愿意并能够完成定期随访。排除标准：(1)有麻醉禁忌证或精神疾病，无法配合完成手术；(2)伴有严重肝肾功能不全、心功能衰竭、呼吸功能不全、凝血功能障碍等；(3)无法配合完成术后随访。

本研究经中国科学技术大学附属第一医院(安徽省立医院)医学伦理委员会批准(2022-R-237)，本研究取得患者知情同意，并同意将其资料用于本研究。

二、方法

患者术前常规行冷敏感试验、Hildreth试验检查及高频彩超、单侧手指正侧位X线检查，对于术前症状不典型、诊断困难者可辅助采用高分辨率磁共振成像检查。行LOVE试验定位瘤体位置后标记。

(一)手术方法

患者取平卧位，指根局部阻滞麻醉满意后，指根扎止血带，手术在头戴式显微镜放大2.5倍下操作。充分游离甲上皮和两侧甲皱襞，使用微小骨剥插入患侧甲板下方，注意保护甲床，钝性分离甲床与甲板，完整拔除指甲。根据术前定位，再次使用微小剥离子由近及远轻柔搔刮甲床表面，可明显感觉质地不均处，即为瘤体准确的位置及边界范围。于瘤体所在甲弧影以远0.5~1.0 mm处(当瘤体位于生发基质以远的甲床区域，则切口为瘤体边界以远0.5~1.0 mm处)，即瘤体远端边界以远的骨质上方做稍大于瘤体最大直径的弧形切口，直达骨质，掀开甲床瓣，使用显微剪刀小心向近端剥离，剥开甲床与骨膜后可见瘤体远端边界外露，沿着瘤体下方分离骨膜，沿瘤体上方小心分离甲床瓣，彻底暴露瘤体，见瘤体均位于甲床下，边界清晰，使用微小剥离子先钝性游离，之后用显微剪轻柔分离，将瘤体连同包膜完全剥除，常可见明显指骨压迹，瘤体呈灰白或黄白色，包膜完整，质地软。使用微小刮匙搔刮指骨压迹处，生理盐水冲洗。原位还纳甲床瓣，不予以缝合，使用5 ml注射器针筒管壁制作甲模板(本组19例术前有甲板畸形的患者和18例术前无甲板畸形的患者中的9例选择使用注射器针筒制作甲模板，其余9例患者选择原甲板制作)，在甲模板上对应甲床切口的区域，使用12号注射器针尖自凹面向凸面戳3~4个引流孔，此时调整甲模板凹凸面曲度，将甲模板近端插于甲上皮下方，见甲模板贴附覆盖于甲床表面，以5-0缝线三点缝合法加压固定甲模板，松止血带，可见甲床血运良好，甲床瓣复位还纳良好，引流孔渗血引流通畅，凡士林覆盖创面后无菌纱布包扎。

(二)术后处理及随访观察

术后第1天换药1次，之后2~3 d换药1次，注意观察甲下积血引流及引流孔血痂形成情况，如发现甲下积血引流不畅，必要时可使用针头挑开引流口血痂，再使用肝素钠注射液冲洗；术后3周拆除固定甲模板的缝线，去除甲模板。记录患者术前及术后1个月疼痛视觉模拟法(visual analogue scale，VAS)评分，并随访观察甲床愈合、疼痛改善、指甲生长及肿瘤复发等情况。

三、统计学分析

采用SPSS 25.0软件进行数据处理，术前、后VAS评分经Kolmogorov-Smirnov检验，数据不符合正态分布，以M(Q1，Q3)表示，采用Mann-Whitney U检验进行分析，P<0.05为差异有统计学意义。

结果

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