V-Y推进皮瓣并甲床直接缝合修复Allen Ⅲ型指尖离断16例

V-Y推进皮瓣并甲床直接缝合修复Allen Ⅲ型指尖离断16例

陆一鸣1,2 王斌1,2 王天亮1,2 王洋1,2 顾加祥1,2 张乃臣1,2

本文来源：《中华整形外科杂志》2023年8月第39卷第8期

DOI:10. 3760 / cma.j.cn114453-20221025-00340

作者单位：1江苏省苏北人民医院手足外科，扬州225001；2扬州大学临床医学院，扬州225009

通信作者：张乃臣，Email：zhangnaichen2004@163.com

引用本文

陆一鸣,王斌,王天亮,等. V-Y推进皮瓣并甲床直接缝合修复Allen Ⅲ型指尖离断16例[J]. 中华整形外科杂志,2023,39(08)：868-872.DOI:10.3760/cma.j.cn114453-20221025-00340

【摘要】

目的探讨V-Y推进皮瓣并甲床直接缝合修复无法行血管吻合的Allen Ⅲ型指尖离断的效果。

方法回顾性分析2018年9月至2020年12月江苏省苏北人民医院收治的Allen Ⅲ型指尖离断患者资料，采用V-Y推进皮瓣并甲床直接缝合修复损伤。术中显微镜下探查见无血管吻合条件，复位末节指骨后以1枚克氏针固定。尽可能拉平甲床后缝合，如若残留间隙，待血痂形成自行生长。根据有无甲板决定是否采用人造甲板覆盖。剔除离断指体掌侧软组织，保留骨膜、甲下皮后，切取V-Y皮瓣达皮下脂肪球，向前推进与甲下皮缝合修复软组织缺损。术后常规采用抗感染治疗，不使用烤灯保温，湿润烧伤膏涂抹保湿。术后观察患指指甲平整度、指腹饱满度，调查患者对外形的满意度，测量两点辨距觉和远指间关节主动屈伸丢失角度。采用中华医学会上肢部分功能评定试用标准评价患指功能。

结果共纳入16例患者(18指)，男9例，女7例；年龄(31.5±6.1)岁(21~52岁)；单指损伤14例，多指损伤2例；损伤指别：拇指2指，示指3指，中指6指，环指5指，小指2指。术后指尖离断体均存活，1例(1指)感染致末节指端轻度骨外露，再次手术治疗后愈合良好，1例(1指)轻度钩甲，余患者对外形均可接受或满意。随访7~16个月(中位时间12个月)，患者全部达到骨愈合，背侧指甲均平整生长，指腹饱满。末次随访时患指指尖两点辨距觉为2.5~4.6 mm,平均3.8 mm；患指远指间关节主动屈曲丢失角度为0°~3.6°，平均2.4°，主动伸直丢失角度为2.0°~12.0°，平均7.6°。患指功能评价：优11例，良3例，可2例。

结论 V-Y推进皮瓣并甲床直接缝合修复无法行血管吻合的Allen Ⅲ型指尖离断，可以较好地保留指尖长度及指甲外形，保留饱满以及感觉良好的指腹，修复成功率高，操作简单，术后外观满意，功能较好。

【关键词】指损伤；再植术；皮瓣；指甲

Fingertip reconstruction with V-Y advancement flap and nailbed suture following Allen’s type Ⅲ amputation: a report of 16 cases

Lu Yiming1,2, Wang Bin1,2, Wang Tianliang1,2, Wang Yang1,2, Gu Jiaxiang1,2, Zhang Naichen1,2

1Department of Foot and Hand Surgery, Northern Jiangsu People’s Hospital, Yangzhou 225001, China; 2Clinical Medical College, Yangzhou University, Yangzhou 225009, China

Corresponding author: Zhang Naichen, Email: zhangnaichen2004@163.com

【Abstract】

Objective To discuss the effect of fingertip reconstruction with V-Y advancement flap and nailbed suture treating Allen’s type Ⅲ amputations unsuitable for vascular anastomosis.

Methods From September 2018 to December 2020, clinical data of patients with Allen’s type Ⅲ fingertip amputations treated in Northern Jiangsu People’s Hospital were analyzed retrospectively. The fingertips were reconstructed with V-Y advancement flap and nailbed suture. The infeasibility of vascular anastomosis was checked under the microscope. Following fixation of the distal phalanx, the nailbed was stretched as flat as possible and sutured. If the nail plate was missing, a manual nail plate made from a plastic transfusion pipe would be fixed to cover the exposed nailbed. The palmar soft tissue of the amputated fingertip was excised, and periosteum, hyponychium, nailbed, and dorsal soft tissue were retained. The proximal volar skin was incised until the subcutaneous adipose layer to get a V-Y advancement flap. The volar defect was repaired with the V-Y advancement flap distally sutured with the pre-retained hyponychium. Postoperatively, burn cream was smeared on the nail for moisturizing, without lamp heating, and intravenous antibiotics was administered routinely. The main indexes were collected including nail appearance, pulp plumpness, static two-point discrimination, motion loss of the distal interphalangeal joint, and patients’ self-evaluation of the appearance. Chinese Medical Association trial standard of upper limb partial function assessment (CMA evaluation) was used to evaluate finger function.

Results A total of 16 patients with 18 fingertips were included. There were 9 males and 7 females, aged (31.5±6.1) years (21-52 years). There were 14 cases of single fingertips injury and 2 cases of multiple fingertips injury. Damaged finger: 2 of thumb, 3 of indicator finger, 6 of middle finger, 5 of ring finger, 2 of little finger. All 18 fingertips survived postoperatively and followed up for 7-16 months (median 12 months). One case underwent a second surgery due to infection and mild bone exposure followed by good healing. One case had a slightly hooked nail. The fingertip appearance was satisfying or acceptable by all the patients except the above two. Good results were got for all patients such as bone healing, smooth nail, plump pulp, and flexible distal interphalangeal joint. At the latest follow-up, motion loss of the distal interphalangeal joint was 0°-3.6° (mean 2.4°) for extension and 2.0°-12.0° (mean 7.6°) for flexion. The static two-point discrimination was 2.5-4.6 mm (mean 3.8 mm). Respectively, the functional evaluation of the affected finger was excellent in 11 cases, good in 3 cases and fair in 2 cases according to the CMA evaluation.

Conclusion Fingertip reconstruction with V-Y advancement flap and nailbed suture is a good technique to treat Allen’s type Ⅲ amputations, with advantages of preserved fingertip length, smooth nail, plump pulp, good sensory and flexible distal interphalangeal joint. The technique is simple with a high success rate and good results.

【Key words】Finger injuries; Replantation; Flap; Nails

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 Northern Jiangsu People’s Hospital (2022ky322).

指尖是手指末梢部分，在日常生活与工作中使用最多，较容易受到损伤。指尖缺损后虽然对手部功能没有明显的影响，但是对外观影响较大，有可能给患者带来严重的心理创伤[ 1 ]。而指尖离断因为解剖学特点致使再植难度较高，损伤原因又以压砸伤多见，离断指体毛细血管床多破坏严重，失去了再植的条件，以往通常采用残端修整或原位缝合。近些年来，国外有学者建议简单化处理，通过定期换药，使近端伤口瘢痕愈合[ 2 , 3 ]，并成为国外此类伤情处理的主流手段。但该方法不能修复外观，国内患者接受度低。因此，如何通过操作简单的手术修复离断指尖的外形和功能成为了研究热点。本研究对无法吻合血管的指尖离断伤采用V-Y推进皮瓣并甲床直接缝合修复，取得了良好的临床效果。

一、资料选择

回顾性分析2018年9月至2020年12月江苏省苏北人民医院收治的采用V-Y推进皮瓣和甲床直接缝合修复AllenⅢ型指尖离断患者的临床资料。纳入标准：(1)AllenⅢ型指尖离断患者；(2)术中无法行血管吻合；(3)患者有保指意愿。排除标准：(1)不能配合术后治疗患者；(2)要求原位缝合的患者。本研究经江苏省苏北人民医院伦理委员会批准(2022ky322)。所有患者对本研究均知情同意，并签署知情同意书。

二、方法

(一)手术方法

采用胶皮条捆绑止血，指根神经阻滞麻醉。先行清创术，清创后探查血管以确定有无再植条件，若无再植条件，则采用V-Y推进皮瓣并甲床直接缝合修复。术中尽可能不使指骨短缩，如粉碎严重，则尽可能减少短缩长度后，采用1枚1.0 mm克氏针贯穿固定远节指骨。背侧甲床甲板近、远端直接缝合，若不能缝合则拉平甲床保留间隙，待血痂形成自行生长。尽可能保留甲板，若甲板缺如则剪取输液器壶部，根据甲板面积自制人工甲板缝合覆盖甲床。剔除离断指体掌侧软组织达骨膜，保留甲下皮以及指骨前方适量软组织，神经断端根据术中情况尽可能和近端软组织平齐。根据掌侧软组织缺损面积及形状，设计掌侧V-Y皮瓣，切至皮下脂肪球，胶皮条松解后充分止血，将"V"形皮瓣向远端推移，皮瓣远端与甲下皮无张力缝合，最终形成"Y"形掌侧伤口( 图1 )。

(二)术后处理及随访

术后即刻观察伤指掌侧V-Y皮瓣血运情况。指体背侧采用烫伤膏涂抹保湿，常规给予抗感染、止痛治疗3 d，不采用烤灯保暖。术后1周，开始主、被动功能锻炼。术后8周根据骨折愈合情况拔除克氏针。所有患者均留有联系方式，采用门诊或上门随访方式。术后2个月评价末节指骨愈合情况；术后3、6个月以及末次随访时评估患指远指间关节主动伸直以及屈曲丢失角度、两点辨距觉、指甲平整度及指腹饱满程度。术后6个月采用中华医学会上肢部分功能评定试用标准[ 4 ]评价患指功能。

三、结果

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