【摘要】：背景： 自上世紀80年代以來,穿支皮瓣得到較大的發(fā)展,在1988年Becker報道了尺動脈腕上皮支皮瓣在臨床上的應(yīng)用,1989年國內(nèi)張高孟等在解剖學研究基礎(chǔ)上,將尺動脈腕上皮支皮瓣應(yīng)用于臨床修復(fù)手部皮膚軟組織缺損創(chuàng)面。尺動脈腕上支皮瓣修復(fù)手部皮膚軟組織缺損從帶蒂皮瓣轉(zhuǎn)移發(fā)展到游離移植,獲得了良好的效果。章文鋒等于2011年報道了帶肌腱的游離尺動脈腕上皮支上行支皮瓣修復(fù)手指軟組織缺損。結(jié)合目前手外傷引起的指背皮膚合并伸指肌腱缺損的修復(fù)主要以單純?nèi)≌崎L肌腱等肌腱移植修復(fù)伸指肌腱,以近節(jié)指背、掌骨背島狀皮瓣或鄰指皮瓣等轉(zhuǎn)位修復(fù)皮膚軟組織缺損,供區(qū)需再取腹部或上臂全厚皮片游離移植,勢必需要有3個供區(qū)來完成修復(fù)。顯然如果用帶部分尺側(cè)屈腕肌腱的尺動脈腕上掌側(cè)穿支皮瓣來修復(fù)指背復(fù)合組織缺損,只要一個供區(qū)就完成了肌腱和皮膚缺損的覆蓋,極大的減少了供區(qū)的損傷和破壞。 目的： 本課題通過對25例26指臨床病例進行6個月-2年的跟蹤隨訪,總結(jié)該皮瓣的存活情況、外觀、感覺恢復(fù)及肌腱愈合情況和指體的伸屈功能等,進一步總結(jié)游離帶肌腱的尺動脈腕上掌側(cè)穿支皮瓣修復(fù)指背皮膚肌腱缺損的臨床應(yīng)用經(jīng)驗,為該復(fù)合皮瓣在指背皮膚軟組織合并伸指肌腱缺損的推廣應(yīng)用提供臨床支持,為解決手部復(fù)合組織缺損修復(fù)提供優(yōu)良的皮瓣覆蓋技術(shù)。 方法： 臨床上在2008年1月至2013年12月對于25例26指指背皮膚軟組織合并伸指肌腱缺損患者,以患肢同側(cè)帶部分尺側(cè)屈腕肌腱的尺動脈腕上掌側(cè)穿支皮瓣對指背皮膚肌腱缺損進行游離移植,術(shù)中帶淺層1/2厚度的尺側(cè)屈腕肌腱長約2.0～5.5cm,并借腱膜保留在皮瓣內(nèi)不分離,保持移植肌腱的血供。術(shù)中進行臨床顯微解剖,進一步總結(jié)該穿支的特點。術(shù)后1周內(nèi)觀察該皮瓣的存活規(guī)律,動靜脈危象發(fā)生情況及處理方法原則。術(shù)后3周、1.5個月、3個月、6個月、1年、2年進行隨訪,觀察該供受區(qū)的外觀以及患指的伸屈功能,總結(jié)該皮瓣的臨床應(yīng)用特點與經(jīng)驗。 結(jié)果： 臨床上25例26指中24指皮瓣成活,隨訪0.5～2年時間,皮瓣不臃腫,修復(fù)神經(jīng)者感覺恢復(fù)S3～S3+級。1指出現(xiàn)動脈危象,經(jīng)手術(shù)探查后成活；3指出現(xiàn)水泡、發(fā)紫,其中1指經(jīng)拆線處理后成活,1指部分壞死,經(jīng)換藥后疤痕愈合,1指完全壞死,二期予植皮術(shù)。隨訪6-24個月,皮瓣色澤與受區(qū)相似,無明顯臃腫,患指伸屈指恢復(fù)正�；蚪咏！Ｍ蟛抗┢^(qū)疤痕攣縮不明顯,腕關(guān)節(jié)活動及屈腕肌腱肌力無影響。 結(jié)論： 尺動脈在腕上掌側(cè)有恒定的皮膚穿支,可用穿支數(shù)量1-3條不等,滿足設(shè)計要求,且該部位的皮膚與指背的皮膚質(zhì)地相近,可行單一肢體麻醉,單一手術(shù)野完成,一個供區(qū)即完成2個組織的缺損修復(fù),患者容易接受。游離腕上穿支皮瓣移植術(shù)后供區(qū)往往可直接縫合,供受區(qū)外觀良好,屈腕功能無影響。因此,對于中小面積指背皮膚軟組織復(fù)合伸指肌腱缺損,游離帶肌腱的尺動脈腕上穿支皮瓣修復(fù)指背皮膚肌腱缺損是一個不錯的選擇,值得臨床推廣應(yīng)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.
【學位授予單位】：浙江大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R658.2

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