三种主力皮瓣-无锡手外科医院强力制作

WuxiHandSurgery&OrthropaedicsHospitalNewworkhorseflapsinhandreconstructionJeffreyB.FriedrichWilliamC.PedersonAllenT.BishopHAND(2012)7:45-54WuxiHandSurgery&OrthropaedicsHospitalIntroductionTheterm“workhorseflap”iscommonlyusedinhandsurgeryandmicrosurgery.Definition:somethingthatismarkedlyuseful,durable,ordependable.Workhorseflapcanbedefinedasonethathasdependableanatomy,easeofharvestandinset,multipleapplications,andmultipleusers.WuxiHandSurgery&OrthropaedicsHospitalIntroductionInthisreview,threecommonhandproblemsarehighlighted:(1)dorsalhandwound.(2)extensivemutilatinghandinjury.(3)scaphoidnonunion.WuxiHandSurgery&OrthropaedicsHospitalDorsalhandwoundAdorsalhandwoundisacommoninjurybecauseofthethinpliablenatureoftheskin.Traumatothisskinwillresultinexposedextensortendonsandmetacarpalbones.Thecurrentacceptedtreatmentisareverseflowradialarterypedicledforearmflap.Shortcomings:poorskingrafttakeonthedonorsiteandnoticeabledonorscar.leadstoabulky“biscuit-like”result.Annewworkhorseflapwouldbetheradialforearmfascia-onlyflap.WuxiHandSurgery&OrthropaedicsHospitalRadialForearmFasciaFlapAnatomy:Thelimitedanatomicresearchthathasbeenperformed.Weknowfromexperiencetheperfusionoftheflapisadequateatleastforaskingraftapplieddirectlytotheflap.Solvestwoproblems:poorappearanceofthedonorsiteandflapbulkinessattherecipientsite.WuxiHandSurgery&OrthropaedicsHospitalRadialForearmFasciaFlapIndications:Anydorsalhandwoundandjustaboutanythumbwound.Difficulttomaketheflapreachthefingertips.Fracturefixationandextensortendonrepairorreconstructioncanbeperformedandtheflapusedtocoverthedorsalhandatthesametime.WuxiHandSurgery&OrthropaedicsHospitalRadialForearmFasciaFlapSeveredorsalhandinjurythatincludesextensorindicisproprius,extensordigitorumcommunis(index),extensorcarpiradialislongusandbrevis,andskinloss.WuxiHandSurgery&OrthropaedicsHospitalRadialForearmFasciaFlapDissectionofthedeepsurfaceoftheflapandthepedicleisperformedaswithanyotherradialforearmflap.Theproximalradialarteryisleftintactbutclamped,andthetourniquetisreleased.WuxiHandSurgery&OrthropaedicsHospitalRadialForearmFasciaFlapTheproximalradialarteryisdividedandtheflaptransferred.Amoderatelythickskingraftisused(0.012–0.015in.),andsmallstabincisionsaredone.WuxiHandSurgery&OrthropaedicsHospitalRadialForearmFasciaFlapHealedradialforearmfasciaflapdemonstratinggoodcontourofthehand.WuxiHandSurgery&OrthropaedicsHospitalTherapyRehabilitationfocusesonrestoringtendonexcursionandjointmotion,whileprotectinginjuredstructures,andflapcontinuity.ThepostoperativesplintpositionstheMPjointsinapproximately30–45°offlexion,withtheinterphalangealjointsextended,andthewristin~30°ofextension.At4–7dayspostsurgery,earlycontrolledmotionmaybestarted.Thesplintingintheseprotocolsmaybediscontinuedandfullactivemotioninitiatedat5–6weekspostrepair.WuxiHandSurgery&OrthropaedicsHospitalAnterolateralThighFreeFlapTheskinoftheanterolateralsurfaceofthethighissuppliedprimarilybyperforatorscomingfromthedescendingbranchofthelateralfemoralcircumflexarteryandveinastheycoursebetweentherectusfemorisandvastuslateralismuscles.Ina2002study,Weiandcolleaguesperformed672anterolateralthighflapsandfoundsixthathadnoskinperforators(eitherintheseptumorthroughthemuscle),forarateofonly0.9%.Theyalsonotedthat87%ofskinperforatorsweremusculocutaneousandonly13%septocutaneous.WuxiHandSurgery&OrthropaedicsHospitalAnterolateralThighFreeFlapTheanterolateralthighflapcanbeutilizedforsofttissuecoverageofanylargewoundoftheforearmand/orhand.Thedescendingbranch,whichsuppliestheflap,canbeutilizedasa“flow-through”vesselincasesofconcomitantvascularinjurytotheforearm,andfascialatacanbeharvestedfortendon/ligamentreconstruction.Ifthereisasignificantdeepdefect,aportionofthevastuslateraliscanbeharvestedtofillthevoid.WuxiHandSurgery&OrthropaedicsHospitalAnterolateralThighFreeFlapViewofpatient'sforearmandhandaftersevereelectricalinjuryandlossofvolarstructures.Planisforcoverageandtendonrods,followedbyinnervatedgracilistransfer.WuxiHandSurgery&OrthropaedicsHospitalAnterolateralThighFreeFlapDrawingastraightlinefromtheanterior–superioriliacspine(ASIS)tothelateralborderofthepatella(LP).Themidpointofthislineismarked,andmostoftheperforatorswillbelocatedafewcentimeterslateraltothislinenearthemidpoint.WuxiHandSurgery&OrthropaedicsHospitalAnterolateralThighFreeFlapFlapinplaceonhandafterexcisionofscarandplacementofsiliconetendonrods.Notebolsteroverfull-thicknessskingraftonthenararea.WuxiHandSurgery&OrthropaedicsHospitalAnterolateralThighFreeFlapFlapat4monthspriortotransferofinnervatedgracilis.WuxiHandSurgery&OrthropaedicsHospitalComplicationsDonorsitemorbidityfromtheharvestoftheanterolateralthighflapislow,andinastudyof220patientsundergoingflaptransfer,Hanasonoandcolleaguesfoundlowratesoflocalandwoundhealingproblems.84%ofpatientsnotednumbnessinthedistributionofthelateralfemoralcutaneousnerve,anddespite37%ofpatientshavingasignificantamountofthevastuslateralsmuscleharvested,allpatientsreturnedtothepreoperativelevelofactivity.WuxiHandSurgery&OrthropaedicsHospitalMedialFemoralCondyleFla