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大鱼际微型穿支皮瓣在拇指近节指腹挛缩修复中的应用

目的 总结大鱼际微型穿支皮瓣修复拇指近节指腹挛缩的方法及疗效。 方法2010年8月－2011年9月，收治拇指近节指腹挛缩患者9例。男6例，女3例；年龄17～60岁，平均45岁。致伤原因：再植术后挛缩 4例，机器绞伤3例，压砸伤2例。瘢痕挛缩3个月～2年。先行挛缩指腹开大，开大后指腹缺损范围为8 mm × 2 mm～30 mm × 15 mm；然后采用大小为25 mm × 10 mm～35 mm × 15 mm的大鱼际微型穿支皮瓣移位修复缺损。供区直接缝合。 结果术后皮瓣完全成活，创面Ⅰ期愈合；供区切口Ⅰ期愈合。患者均获随访，随访时间6～12个月，平均9个月。皮瓣外形良好，质地柔软。拇指背伸80～90°及外展90°。瘢痕无复发；大鱼际切口无瘢痕挛缩，拇指关节活动正常。末次随访时手功能按中华医学会手外科学会上肢部分功能评定试用标准评定，获优8指，良1指。 结论大鱼际微型穿支皮瓣具有不损伤主干动脉的优点，是修复拇指近节指腹挛缩的理想方法之一。

微型外固定支架在虎口外伤急诊治疗中的应用及疗效

目的探讨微型外固定支架在急诊治疗虎口外伤中的应用及临床疗效。 方法2009年2月－2011年6月，收治虎口外伤患者34例。男21例，女13例；年龄18～65岁，平均31.4岁。致伤原因：机器冲压伤15例，重物压砸伤12例，切割伤5例，爆炸伤2例。受伤至入院时间20 min～6 h 30 min。按创伤程度及范围，26例为简单损伤，8例为复合性损伤。急诊清创后一期微型外固定支架开大虎口或联合虎口“Z”字成形治疗，复合性损伤者二期行皮瓣修复。 结果术后1例发生针道感染，经对症处理后愈合；其余患者切口均Ⅰ期愈合，复合性损伤患者皮瓣及供区植皮均顺利成活。31例获随访，随访时间5～14个月，平均7.5个月。末次随访时虎口开大角度为65～95°，平均80°。拇指指间关节纹尺侧点与示指掌指关节桡侧点距离为4.0～5.5 cm，平均4.8 cm；按顾玉东等的评价方法评价，获优19例，良10例，差2例，优良率达93.5%。 结论在虎口外伤急诊治疗中，采用微型外固定支架开大虎口，手术操作简便，损伤小，避免了虎口挛缩的发生。

INVESTIGATION OF NEW CLASSIFICATION AND REPAIR METHODS FOR FINGERTIP TRAVERSE AMPUTATION

Objective To investigate new classification and repair methods for the traverse amputated fingertip. Methods From March 2000 to October 2006, 20 cases of 20 fingers with traverse amputated fingertip, including 13 males and 7 females aged 17-47 years, were treated. Twenty patients (9 crush injuries, 5 cutting injuries and 6 sawing injuries) were classified into 4 types, namely type I (the distal one third of nail bed), type II (the middle of nail bed), type III (the poximal one third of nail bed), and type IV (the root of nail bed). There were 3 patients (2 index fingers and 1 l ittle finger) of type I, 8 patients (2 thumbs, 3 index fingers and 3 middle fingers) of type II, 5 patients (3 index fingers, 1 ring finger and 1 l ittle finger)of type III, and 4 patients (2 thumbs, 1 middle finger and 1 l ittle finger) of type IV. The soft tissue defect ranged from 1.2 cm × 1.2 cm to 1.5 cm × 1.2 cm. The time from injury to surgery was 3-10 hours. Fingers of type I and type II were treated with forward flow axial flap and modified nail bed lengthening. Fingers of type III and type IV were treated with forward flow axial flap and partial nail bed replantation as well as modified nail bed lengthening. The flaps ranged in size from 1.5 cm × 1.2 cm to 2.0 cm × 1.4 cm. Results Twenty patients incisions healed by first intention and the flaps, nails and skin grafting survived. All donor sites healed by first intention. All patients were followed up for 2-6 months (4 months on average). The appearances of fingertips were good. The texture of the flap was soft, and the fingers had no tenderness and motor disturbance. The two-point discrimination was 4.5-6.5 mm．The finger nails of type I and type II extended 3-4 mm after operation, while the finger nails of type III and type IV extended 8-10 mm after operation. All finger nails were smooth and flat without pain. Hook nail happened in 1 case 6 months after operation. Conclusion Classification of the injured fingers according to the condition of the amputation base is helpful in choosing repair methods, and is conducive to maximize the recovery of the function and shape of fingertips.

双蒂腹部真皮下血管网皮管修复2 ～ 5 指双指脱套伤

目的 总结双蒂腹部真皮下血管网皮管修复2 ～ 5 指双指脱套伤的临床效果。 方法 2003 年2 月－ 2006 年8 月，采用双蒂腹部真皮下血管网皮管修复6 例双指脱套伤。男4 例，女2 例；年龄17 ～ 45 岁。示、中指2 例，中、环指3 例，环、小指1 例。撕脱平面均于近节指横纹以远，伴不同程度肌腱及关节囊损伤、骨外露。损伤至手术时间为40 min ～ 5 d。术中设计7 cm × 5 cm ～ 12 cm × 7 cm 双蒂腹部真皮下血管网皮管修复缺损。 结 果 1 例2 指术后2 周断蒂，术后2 d 皮管远端表皮坏死，经换药后愈合；余5 例10 指术后3 周断蒂，皮管均顺利成活，伤口Ⅰ期愈合。腹部供区Ⅰ期愈合。6 例术后均获随访，随访时间3 ～ 12 个月。皮瓣外形恢复较满意，手功能按ATM 标准评分：优2 例，良3 例，中1 例。 结论 双蒂腹部真皮下血管网皮管具有手术操作简便、术后患者对手功能及外形恢复满意的优点，是修复2 ～ 5指双指脱套伤的理想方法之一。

REPLANTATION OF COMPLEX THUMB MUTILATION WITH LOCAL ISLAND FLAP

Objective To investigate the cl inical effect and operative method of local island flap for complex thumb mutilation with soft tissue and blood vessel defect. Methods From May 2003 to March 2006, 6 cases of complex thumb mutilation with soft tissue and blood vessel defect were treated with local island flap. There were 4 males and 2 females aged 14-48 years, with an average of 23.5 years, among whom 2 cases were caused by triangular bandage twist, 3 cases by machinesavulsion and 1 case by explosion. Five cases suffered thumb mutilation of soft and blood vessel defect only, and 1 case was combined with middle and ring finger injures. The defect was located in pulp soft tissue in 4 cases and in dorsal soft tissue in 2 cases, ranging 2.0 cm × 1.2 cm-2.5 cm × 1.8 cm in size. The time from injury to operation varied from 30 minutes to 6 hours. Two cases were replanted with bridging index finger radial is digital artery island, 2 cases were repaired by ring finger radial is digital artery island and 2 cases by index finger near dorsi-flap. The flap was 2.0 cm × 1.4 cm-2.5 cm × 1.8 cm in size. Free-skin graft from forearm was conducted. Results All flaps free skin and replanted thumbs in 6 cases survived completely, following up for 6-24 months after operation. The flaps and thumb had good texture and color match, two-point discrimination was 10-12 mm on thumb pulp and 8-10 mm on flap. All replanted thumb recovered satisfied function, there were no donor site dysfunction. According to the criteria for function assessment of amputated finger issued by the Branch of Hand Surgery of Chinese Medicine Association：4 cases were regarded as excellent and 2 as good. Conclusion Local island flap is capable of repairing complex thumb mutilation with soft tissue and blood vessel defect, maximizing the recovery of thumb appearance and function.

吻合血管的游离组织移植修复小儿四肢软组织缺损

多束法缝合结合术后早期半弧主动屈伸治疗手指Ⅱ区屈肌腱损伤

目的总结多束法缝合结合术后早期半弧主动屈伸治疗手指Ⅱ区屈肌腱损伤的临床疗效。 方法2008年3月－2014年9月，对87例（189指）手指Ⅱ区屈肌腱损伤患者采用多束法缝合修复屈肌腱，术后早期行半弧主动屈伸练习。其中男58例，女29例；年龄21～69岁，平均43岁。致伤原因：锐器切割伤34例，电锯伤47例，机器挤压伤6例。损伤指别：示指64指，中指75指，环指45指，小指5指。受伤至手术时间1～6 h，平均4.5 h。使用Strickland-Glogovac标准评价术后手指功能恢复。 结果术后患者伤口均Ⅰ期愈合，无感染发生。87例均获随访，随访时间6～14个月，平均9个月。末次随访时功能评价获优143指，良29指，可15指，差2指，优良率91%。1例出现屈肌腱再断裂。 结论多束法缝合肌腱结合术后早期半弧主动屈伸是一种治疗手指Ⅱ区屈肌腱损伤安全且有效的方法。

Experimental study on the causes of spontaneous osteogenesis of Masquelet technique induced membrane

ObjectiveTo investigate the causes of spontaneous osteogenesis of Masquelet technique induced membrane. MethodsForty-two male Sprague-Dawley rats aged 7-9 weeks were selected to establish a critical-sized bone defect of the right middle femur model. Then the rats were randomly divided into 4 groups, with 12 rats in groups A-C and 6 rats in group D. The bone defects in groups A-C were filled with vancomycin-loaded polymethyl methacrylate bone cement spacers. Then the Kirschner wires were used for intramedullary fixation in groups A and B, and the bone cement was used to connect the bone cement spacers and the bone ends in group B. The steel plate was used to fixation in group C. The bone defect in group D was only fixed with steel plate as a blank control group. The general condition was observed after operation. At 5 weeks after operation, 6 rats in groups A-C were selected for STRO-1 immunohistochemical staining to observe the content of mesenchyme stem cells (MSCs) in the induced membrane (STRO-1+ cells). At 12 weeks after operation, the remaining rats in groups A-D were taken for X-ray observation, gross observation, and histological observation (HE, safranin O-green staining) to observe the spontaneous osteogenesis of the membrane.Results All rats in the 4 groups survived until the completion of the experiment. At 5 weeks after operation, the immunohistochemical staining showed that group B was negative, while the contents of MSCs in the induced membrane in groups A and C were 14.20%±1.92% and 5.00%±0.71%, respectively, with a significant difference (P<0.05). At 12 weeks after operation, group A showed that the new bone formed at the osteotomy site and growth towards the center of the bone defect, with an average length of 3.1 mm on one side; and the presence of bone, cartilage lesions, fibers, and a small amount of neovascularization were observed in the induced membrane. Group C only had a small amount of new bone at the osteotomy site, and a small amount of neovascularization in the induced membrane. Groups B and D did not have any new bone, but bone resorption or atrophy at the osteotomy site. ConclusionAlthough the Masquelet technique induced membrane has osteogenesis, the key factor for the spontaneous osteogenesis is the bone marrow overflow from the bone marrow cavity providing MSCs. The spontaneous osteogenesis of the induced membrane belongs to endochondral ossification.

PROCESSING STRATEGY OF DIFFICULT REMOVAL OF SCREWS IN PLATE

ObjectiveTo investigate the countermeasures for difficult removal of screws in the plate. MethodsThe clinical data were retrospectively analyzed from 47 patients having difficult removal of screws in the plate between January 2004 and May 2014. There were 30 males and 17 females, aged 16-58 years (mean, 34 years). The time from internal fixation to removal of internal fixation was 10 months to 20 years (mean, 22 months). The locations of internal fixation were upper extremity in 25 cases and lower extremity in 22 cases. The number of difficult removal screws in the plate was 1 in 18 cases, 2 in 15 cases, 3 in 9 cases, and 4 in 5 cases. The plate types included general plate in 15 cases and locking plate in 32 cases; stainless steel plate in 10 cases and titanium plate in 37 cases. The reason for difficult removal, plate, screw, incision, and bone quality of patient were comprehensively analyzed, and different methods for difficult removal were chosen according to the principle that first simply then complicated. ResultsAll plates and screws were removed, and no iatrogenic fracture or nerve and vascular injuries occurred. The operation time was 65-270 minutes (mean, 125 minutes). The blood loss was 80-775 mL (mean, 157 mL). The postoperative drainage was 20-250 mL (mean, 92 mL). The incision healing by first intention was obtained in 39 cases, and delayed healing in 8 cases. The patients were followed up 3-24 months (mean, 10 months). No infection or re-fracture was observed. ConclusionThere are many countermeasures for difficult removal of screws in the plate, but each has indication. As long as a well arranged preoperative condition, mastering a variety of methods, and being familiar with its indication, as well as reasonably choosing method based on the specific situations, the plate and screw maybe smoothly removed.

指动脉串联逆行岛状皮瓣修复老年指端脱套伤

目的总结指动脉串联逆行岛状皮瓣修复老年指端脱套伤的疗效。 方法2011年6月－2012年8月，收治7例老年指端脱套伤。男5例，女2例；年龄56～68岁，平均62岁。致伤原因：冲压伤4例，机器绞伤3例。损伤指别：示指3例，中指3例，环指1例。合并末节指骨骨折2例，伸肌腱止点撕脱1例，相邻指损伤1例。伤后至手术时间为3～5 d，平均3.6 d。术中在患指切取近节指根部及掌远端2块皮瓣瓦合修复指端皮肤软组织缺损；近节指根部侧方皮瓣切取范围为1.4 cm × 1.2 cm～2.0 cm × 1.8 cm，掌远端皮瓣为1.1 cm × 1.0 cm～1.8 cm × 1.5 cm。掌远端供区直接缝合，指根部供区游离植皮修复。 结果1例掌远端皮瓣术后12 h发生静脉危象，经间断拆线后缓解；其余皮瓣及供区植皮均顺利成活，创面Ⅰ期愈合。术后7例均获随访，随访时间6～20个月，平均12个月。皮瓣外形、质地均良好。末次随访时，近节指根部侧方皮瓣两点辨别觉为7～10 mm，掌远端皮瓣为8～12 mm；手指功能参照中华医学会手外科学会上肢部分功能评定试用标准：获优6例，良1例。 结论指动脉串联逆行岛状皮瓣是利用远侧指间关节指固有动脉交通支的解剖特点，将相邻的2块皮瓣瓦合修复老年患者指端脱套伤，手术操作简便，疗效满意。