第2足趾腓侧皮瓣的解剖研究及在手部皮肤缺损中的应用
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摘要
背景：游离皮瓣移植为修复手部皮肤缺损的重要方法，而与手部皮肤颜色、质地、弹性相似的足部皮瓣最为常用，并获得了很好的效果。但在应用过程中发现，足背皮瓣、(足母)甲皮瓣、(足母)趾腓侧皮瓣等以牺牲足背动脉或第1跖背动脉等主干血管为代价的足部皮瓣，供足出现较多的并发症。随着显微外科解剖学研究的深入，手外科技术的不断提高，足部不损伤主干动脉的皮瓣已有临床应用，但第2趾腓侧皮瓣移植修复手指皮肤缺损尚未见报道。
目的：(1)探讨第2趾腓侧皮瓣相关血管、神经的位置、走行和外径，皮瓣的可切取范围：(2)该皮瓣的临床应用可行性、优缺点、适应证、手术方法和注意事项等。
方法：新鲜成人尸体足左、右侧各10只，经足背动脉灌注乳胶，解剖、测量，观察乳胶在第2趾皮肤的灌注范围，测量皮瓣的腓侧固有动脉、趾背动脉、趾背静脉、趾固有神经、趾背神经及与之关系密切的第2跖背动脉、第2跖背静脉等的外径。临床应用17例第2趾腓侧皮瓣修复手指皮肤缺损，观察皮瓣成活率、有无感染、植皮坏死及外观、功能情况等。
结果：经过乳胶灌注，解剖见：灌注液可达第2、3跖骨背间隙背侧6cm×8cm皮肤、第2、3趾和拇趾；测得在第2趾跖趾关节处血管、神经外径分别为：第2跖背动脉(1.8±0.2)mm，第2跖背静脉(1.4±0.2)mm，第2跖底动脉(1.5±0.2)mm，第2趾腓侧固有动脉(1.0±0.2)
咖，第2趾背动脉(0 .7士0.2)InIn，第2趾背静脉(0.9士0.2)llun，第2
趾排侧固有神经和趾背神经分别为(1 .4士0.2)Inln、(0.5士0.2)伽。
临床选择17例手指皮肤缺损的病例，进行第2趾排侧皮瓣移植修
复，全部皮瓣成活，无感染，除一例因手指指端严重挤压伤，指端坏
死去除，另一例足部植皮部分坏死经换药愈合外，其余足部和手部均
一期愈合，经4个月以上随诊，手指皮瓣外观好，感觉基本正常，功能
恢复满意。足部无疼痛、跋行等并发症。
结论:第2趾胖侧皮瓣血供可靠，口径适宜吻合，可同时携带第2
拓背动脉皮瓣，皮瓣质地、外观好，对供足影响小，适合于手指皮肤
缺损修复。
Background: Free skin flap is an important method for manus cutaneous deficiency treatment and the skin flaps from feet are most frequently used with satisfying results as its color, quality and elasticity are similar to those of manus. However, people found that flaps like dorsum pedis skin flap, great toe skin flap, the great toe fibular skin flap, which sacrificed the some principal blood vessel like dorsalis pedis or dorsal metatarsal artery, could bring many complications to the donator foot. With the advances in microsurgery anatomy and the improvements of manus surgery techniques, skin flaps that don't do harm to principal arteries have been introduced to clinic but there hasn't been a report on application of fibula side flap of the second toe in manus cutaneous deficiency treatment.
Objective: To study the diameter of vessels and nerves that related to the fibula side flap of the second toe, the dimension of the flap and its possibility, advantages, disadvantages, application and announcements in clinic.
Method: 10 left feet and 10 right feet from newly dead adults were obtained and red lacteprene was instilled through dorsalis pedis artery. After that, the feet were dissected, the dimension of lacteprene was measured and the diameter of fibular intrinsic artery, fibular dorsal digital arteries, dorsal digital veins of foot, digital intrinsic arteries and
dorsal digital nerves of foot of the flap and the second dorsal metatarsal artery and dorsal metatarsal veins that closely related to the flaps. In clinic, 17 patients with finger cutaneous deficiency received the treatment of fibula side flap of the second toe with observation like flap survival rate, infection, necrosis, appearance and function.
Results: Filling by lacteprene, after dissection we found: perfusates can reach 6mm X 8mm dorsal interspace back skin between the second and third metatarsal bone; we measured the diameter of blood vessels and nerves near the second metatarsophalangeal joint,as follow:the second dorsal metatarsal artery (1. 8+0. 2) mm, the second dorsal metatarsal vein(l. 4+0. 2)mm, the second basic-metatarsus artery
(1. 5+0. 2) mm, the second dactylo-fibular proper artery (1. 0 +0.2) mm, the second dorsal digital artery (0. 7+0. 2) mm, the second dorsal digital vein ( 0.9 + 0.2 ) mm , the second dactylo-fibular proper nerve and dorsal digital nerve of foot
(1.4+0. 2)mnu (0. 5+0. 2) mm0
To the 17 patients, all the flaps survived and there wasn't infection seen. All the wounds on finger were confirmed to be primary healing except that the fingertip of one patient was cut off because of severe crush injury and one patient had got necrosis on the grafted skin on foot, which was cured by continuous dressing change. After 4 months of follow-up, grafted flaps presented good appearance with basically normal sensation and satisfying functional restoration. What's more, no complication of the foot, like lameness or pain, was observed.
Conclusion: Fibula side flap of the second toe was suitable for manus cutaneous deficiency treatment as it provided stable blood supply, had appropriate vessels for anastomosis, the quanlity and appearance were nice and had little influence on the donator foot.
目的：(1)探讨第2趾腓侧皮瓣相关血管、神经的位置、走行和外径，皮瓣的可切取范围：(2)该皮瓣的临床应用可行性、优缺点、适应证、手术方法和注意事项等。
方法：新鲜成人尸体足左、右侧各10只，经足背动脉灌注乳胶，解剖、测量，观察乳胶在第2趾皮肤的灌注范围，测量皮瓣的腓侧固有动脉、趾背动脉、趾背静脉、趾固有神经、趾背神经及与之关系密切的第2跖背动脉、第2跖背静脉等的外径。临床应用17例第2趾腓侧皮瓣修复手指皮肤缺损，观察皮瓣成活率、有无感染、植皮坏死及外观、功能情况等。
结果：经过乳胶灌注，解剖见：灌注液可达第2、3跖骨背间隙背侧6cm×8cm皮肤、第2、3趾和拇趾；测得在第2趾跖趾关节处血管、神经外径分别为：第2跖背动脉(1.8±0.2)mm，第2跖背静脉(1.4±0.2)mm，第2跖底动脉(1.5±0.2)mm，第2趾腓侧固有动脉(1.0±0.2)
咖，第2趾背动脉(0 .7士0.2)InIn，第2趾背静脉(0.9士0.2)llun，第2
趾排侧固有神经和趾背神经分别为(1 .4士0.2)Inln、(0.5士0.2)伽。
临床选择17例手指皮肤缺损的病例，进行第2趾排侧皮瓣移植修
复，全部皮瓣成活，无感染，除一例因手指指端严重挤压伤，指端坏
死去除，另一例足部植皮部分坏死经换药愈合外，其余足部和手部均
一期愈合，经4个月以上随诊，手指皮瓣外观好，感觉基本正常，功能
恢复满意。足部无疼痛、跋行等并发症。
结论:第2趾胖侧皮瓣血供可靠，口径适宜吻合，可同时携带第2
拓背动脉皮瓣，皮瓣质地、外观好，对供足影响小，适合于手指皮肤
缺损修复。
Background: Free skin flap is an important method for manus cutaneous deficiency treatment and the skin flaps from feet are most frequently used with satisfying results as its color, quality and elasticity are similar to those of manus. However, people found that flaps like dorsum pedis skin flap, great toe skin flap, the great toe fibular skin flap, which sacrificed the some principal blood vessel like dorsalis pedis or dorsal metatarsal artery, could bring many complications to the donator foot. With the advances in microsurgery anatomy and the improvements of manus surgery techniques, skin flaps that don't do harm to principal arteries have been introduced to clinic but there hasn't been a report on application of fibula side flap of the second toe in manus cutaneous deficiency treatment.
Objective: To study the diameter of vessels and nerves that related to the fibula side flap of the second toe, the dimension of the flap and its possibility, advantages, disadvantages, application and announcements in clinic.
Method: 10 left feet and 10 right feet from newly dead adults were obtained and red lacteprene was instilled through dorsalis pedis artery. After that, the feet were dissected, the dimension of lacteprene was measured and the diameter of fibular intrinsic artery, fibular dorsal digital arteries, dorsal digital veins of foot, digital intrinsic arteries and
dorsal digital nerves of foot of the flap and the second dorsal metatarsal artery and dorsal metatarsal veins that closely related to the flaps. In clinic, 17 patients with finger cutaneous deficiency received the treatment of fibula side flap of the second toe with observation like flap survival rate, infection, necrosis, appearance and function.
Results: Filling by lacteprene, after dissection we found: perfusates can reach 6mm X 8mm dorsal interspace back skin between the second and third metatarsal bone; we measured the diameter of blood vessels and nerves near the second metatarsophalangeal joint,as follow:the second dorsal metatarsal artery (1. 8+0. 2) mm, the second dorsal metatarsal vein(l. 4+0. 2)mm, the second basic-metatarsus artery
(1. 5+0. 2) mm, the second dactylo-fibular proper artery (1. 0 +0.2) mm, the second dorsal digital artery (0. 7+0. 2) mm, the second dorsal digital vein ( 0.9 + 0.2 ) mm , the second dactylo-fibular proper nerve and dorsal digital nerve of foot
(1.4+0. 2)mnu (0. 5+0. 2) mm0
To the 17 patients, all the flaps survived and there wasn't infection seen. All the wounds on finger were confirmed to be primary healing except that the fingertip of one patient was cut off because of severe crush injury and one patient had got necrosis on the grafted skin on foot, which was cured by continuous dressing change. After 4 months of follow-up, grafted flaps presented good appearance with basically normal sensation and satisfying functional restoration. What's more, no complication of the foot, like lameness or pain, was observed.
Conclusion: Fibula side flap of the second toe was suitable for manus cutaneous deficiency treatment as it provided stable blood supply, had appropriate vessels for anastomosis, the quanlity and appearance were nice and had little influence on the donator foot.
引文
1.O' Brien B. Microvascular free toe transfer. Clin Plast Surg, 1987, 5:223
2. Foucher G, Uerk M. Microsurigical free parital to transfer in hand reconstruction. Plast Reconstr surg, 1980, 65:616
3. Yoshimura M. Toe-to-hand transfer. Plast Reconstr Surg, 1980, 66:74-83
4. Tsai TM. Vascularized autogenous whole joint transfer in the hand-a clinical study. Hand Surg, 1982, 7:335
5．孙博，顾玉东，钟世镇，等．第2足趾第2套供血系统探讨．临床应用解剖学杂志，1984，2：129—133．
6．钟世镇，徐达传，丁自海．显微外科临床解剖学．第一版．济南：山东科技出版社，2000，506—514．
7．文质君，徐达传，钟世镇．部分第2、3趾移植再造指部分缺损的外科解剖．中国临床解剖学杂志，1995，13：34—35．
8．蔡锦方，丁自海，陈中伟．显微足外科学．第一版．济南：山东科技出版社，2002，540—542．
9．刘亚平，黄耀添，褚晓朝．第2趾的显微解剖学研究．第四军医大学学报，1995，358—361．
10．劳杰，顾玉东，熊良俭，等．第2跖背动脉的应用解剖学研究．中华手外科杂志，1999，15：248—250．
11．顾玉东．手的修复与再造．上海：上海医科大学出版社，1995，195—199．
2. Foucher G, Uerk M. Microsurigical free parital to transfer in hand reconstruction. Plast Reconstr surg, 1980, 65:616
3. Yoshimura M. Toe-to-hand transfer. Plast Reconstr Surg, 1980, 66:74-83
4. Tsai TM. Vascularized autogenous whole joint transfer in the hand-a clinical study. Hand Surg, 1982, 7:335
5．孙博，顾玉东，钟世镇，等．第2足趾第2套供血系统探讨．临床应用解剖学杂志，1984，2：129—133．
6．钟世镇，徐达传，丁自海．显微外科临床解剖学．第一版．济南：山东科技出版社，2000，506—514．
7．文质君，徐达传，钟世镇．部分第2、3趾移植再造指部分缺损的外科解剖．中国临床解剖学杂志，1995，13：34—35．
8．蔡锦方，丁自海，陈中伟．显微足外科学．第一版．济南：山东科技出版社，2002，540—542．
9．刘亚平，黄耀添，褚晓朝．第2趾的显微解剖学研究．第四军医大学学报，1995，358—361．
10．劳杰，顾玉东，熊良俭，等．第2跖背动脉的应用解剖学研究．中华手外科杂志，1999，15：248—250．
11．顾玉东．手的修复与再造．上海：上海医科大学出版社，1995，195—199．