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題 名 | An Alternative to Thumb Replantation--Amputated Phalanges as Free Graft and Pedicled Groin Flap for Thumb Reconstruction=拇指重建替代方案的個案報告--使用截肢的指節和鼠蹊部皮瓣來做大拇指截肢的重建 |
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作 者 | 林士隆; 張立人; 劉奕添; 陳宏基; | 書刊名 | 臺灣整形外科醫學會雜誌 |
卷 期 | 20:3 2011.09[民100.09] |
頁 次 | 頁243-251 |
分類號 | 416.45 |
關鍵詞 | 拇指重建; 截肢; 顯微手術; Thumb amputation; Alternative; Composite tissue transfer; |
語 文 | 英文(English) |
中文摘要 | 背景:顯微手術已爲治療手指截肢的主流。對於手指之撕脫性截肢,血管常被拉扯出來而且受創區往往相當廣泛;再加上斷指附近的軟組織也因爲外力受創而喪失,使血管接和後缺乏軟組織覆蓋血管的窘境。在拇指截肢的病患,由於拇指佔了手功能的40%,更不能輕言截肢。如何在第一時間內將無法用顯微手術重接的斷指接回,避免掉日後複雜的顯微重建手術或多次手術是個難題。目的及目標:運用複合組織移植的方式保留無法顯微重接的拇指殘肢的骨頭和肌腱,同時用鼠蹊皮瓣來做軟組織的重建。材料及方法:病例報告:一個49歲男性病人左手大拇指被機器以脫手套的方式截肢。由於外傷範圍廣及第一掌骨部位,若要行斷指顯微重接,血管則會暴露在外,因而不可行。術中我們將病人的皮膚軟組織移除,保留骨頭和肌腱,再用鋼釘內固定將截肢的拇指指骨植回截肢端,同時用管狀鼠蹊皮瓣來做軟組織的重建。術後三週分離皮瓣及做修整手術,並於6週後拔除骨釘及行皮瓣減積修薄手術。病人最終的追蹤爲術後2年9個月。結果:拔除鋼釘後發生骨接合部位斷裂的情形。皮瓣的縫合傷口也發生癒合較慢的情形,但是在保守治療後也有達到骨癒合及傷口癒合的狀態。在兩年九個月的最後追蹤,大拇指的骨接合部位完全癒合但是遠端指骨被吸收掉。病人患肢的握力爲健側的88.2%,拇指-食指捏力爲健側的92.3%。患側拇指沒有兩點分辨的能力但是有部分的本體感覺,可以感受壓力,Semmes-Weinstein測試感覺閾值爲健側的25倍。大拇指掌指關節主動活動度爲正常肢的60%。病人爲右手工作者,左手平時是輔助右手的工作。但是病人可以用左手拇指食指夾掏耳棒挖耳朵,而這是右手所不能代替的。整體而言,病人對重建結果感到滿意。結論:在手指撕脫性截肢合併軟組織缺損而顯微斷肢重接不可行時,仍可以盡量保留斷肢可用部分再以軟組織包裹方式重建。骨癒合時間會稍久而且由於本體及壓力感覺在骨癒合初期無法提供精密的施力回饋,容易導致原先骨固定部位骨折,選擇較久的鋼釘固定時間或用鈦合金鋼板做內固定是被建議的。遠端骨頭可能會被吸收,本體感覺會部分回復但閾值高,但兩點感覺則不會恢復。 |
英文摘要 | Background:Microsurgical replantation has generally been used to treat digit amputation. However, avulsed/degloving amputation of the finger, generation of an extensive trauma zone due to pull-out force, and soft tissue loss make replantation difficult because of the lack of soft tissue to cover the replanted pedicle. Thumb replantation is always attempted because it retains 40% of the hand function. In cases of extensively avulsed amputation of the thumb, it is difficult to replant the thumb without using the other flap and performing multiple surgeries.Aim and Objectives:By using the concept of composite tissue transfer, we can preserve the non-replantable thumb bone and tendon and use it as a graft for replantation. The exposed bone and extensive soft tissue injury defect are reconstructed with a pedicled groin flap.Material and Methods:Case report: A 49-year-old male laborer sustained avulsion amputation of the left thumb because of a press machine. The soft tissue defect extended to the first dorsal metacarpal area, and the pedicle would be exposed if replantation was performed only on the trauma area; hence, simple replantation was not possible without other flap reconstruction. We removed the skin of the amputated part and preserved the bone and tendon. The graft was fixated to the amputee with K pins, and then the bone graft and soft tissue defect were covered with a tube groin flap. At 3 weeks after the operation, the pedicle was divided and the stump was revised. The K pins were removed 6 weeks after initial osteosynthesis and flap debulky and thinning were performed. The patient was finally followed-up at 2 years and 9 months after surgery.Result:A fracture of the proximal phalanx was sustained again at the osteosynthesis site and healing was slow, but after conservative treatment, the wound healed eventually. At the 2-year and 9-month final follow-up, the osteosynthesis site showed complete healing despite an absorbed distal phalanx. The grip force and pinch force was 88.2% and 92.3% of the normal site, respectively. The reconstructed thumb had no two point discrimination but retaining some proprioceptive sensation and Semmes-Weinstein test was 25 times of the normal thumb. The metacarpal-phalangeal joint active range of motion was 60% of the opposite thumb. The patient is a right-handed worker and left hand is mainly assisting the right hand for daily life. The patient can pinch the fine cotton swab to clean the left ear, which is not easily to be done by right hand. Generally speaking, the patient is satisfied with the result.Conclusion:In cases of degloving amputation with extensive soft tissue injury when replantation is not possible without extra soft tissue coverage, the amputated part can be used as a graft and all soft tissues can be reconstructed with one flap such as the groin flap. The bone healing time would be longer than usual fracture and the pressure/proprioception sensations are not as good in early healing periods. The site of osteosynthesis is very susceptible to a refracture. In such cases, the use of K pins, which facilitate fixation for a longer period, or the use of secure titanium plates is suggested. The distal bone might be absorbed. There might be partial recovery of the proprioceptive sensation with higher threshold and two-point-discrimination might not recover. |
本系統中英文摘要資訊取自各篇刊載內容。