目的:探讨应用分叶股前外侧穿支皮瓣（ALTPF）游离移植修复四肢软组织缺损创面的手术方法。方法:2010年1月-2021年5月，根据四肢软组织缺损、形态不规则、不连续的特点，海南中德骨科医院手足外科设计切取分叶ALTPF游离移植修复四肢软组织缺损创面26例，其中10例大面积缺损面积为13 cm×12 cm~22 cm×19 cm，13例为邻近不相连的创面，3例为贯通型创面。供区创面均直接缝合。出院后主要通过门诊、电话、微信等方式进行定期复查随访，观察皮瓣的血运、肤色、外观、出汗、质地、温度、痛觉、触觉、TPD、有无破溃及供区恢复情况。结果:术后26例患者移植皮瓣均成活。其中2例皮瓣边缘小面积坏死，反复换药后愈合；1例术后48 h内发生静脉危象，积极探查处理，重新吻合血管后皮瓣成活；1例24 h内发生血肿压迫出现血管危象，给予拆除部分缝线充分引流后皮瓣成活。24例患者获得随访，随访时间6~18个月，平均14个月，皮瓣外形良好、无臃肿，质地柔软，色泽正常，感觉功能恢复良好。供区仅留线形瘢痕，外观、功能无明显影响。参照《手外科手术学》的皮瓣综合评定标准，结果优18例、良6例。结论:分叶ALTPF疗效满意，是修复四肢创面的一种较好的手术方法。

Objective:To explore the surgical procedure and clinical effect of a free transverse carpal flap based on the superficial palmar branch of radial artery in reconstruction of soft tissue defect of digits.Methods:From February 2014 to May 2022, 17 cases of soft tissue defects with tendon or phalanges in digits were treated in the Department of Hand and Foot Surgery, Hainan Zhongde Orthopaedic Hospital. All 17 cases were treated by the free transverse carpal flap based on the superficial palmar branch of radial artery. The flap size was 2.0 cm×2.0 cm-4.5 cm×2.0 cm. The anastomosed artery was digital artery or common digital artery, and the vein was the accompanying vein or superficial subcutaneous vein. All donor sites were directly sutured. Preventive measures of anti-infection, anticoagulation, anti-vasospasm and symptomatic treatment were given after surgery. After discharge of patients, scheduled follow-ups were conducted through outpatient clinic, telephone or WeChat interviews to observe the clinical effects. According to the Evaluation Standard of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, hand functional recovery was good in 14 cases and good in 1 case.Results:All 17 flaps had survived with 16 completed the postoperative follow-up. Follow-ups ranged from 6 to 18 months, with a mean of 14 months. At the last follow-up, the flaps were good in shape, soft texture, in normal flexion and extension and with good protective sensation. Two-point discrimination (TPD) was 8-12 mm, with an average of 8 mm. There was no other adverse effect in the donor sites except a linear scar.Conclusion:Application of transverse carpal flap based on the superficial palmar branch of radial artery from same limb to restore the digit function is feasible. It is an ideal surgical procedure of flap transfer.

目的:探讨游离 甲瓣联合髂骨移植在I~II度拇指缺损全形再造术中临床应用的选择和治疗效果。 方法:2018年5月至2021年3月,收治拇指缺损患者18例,I度缺损10例,II度缺损8例。根据拇指缺损长度设计切取同侧 甲瓣联合髂骨移植再造拇指,将 甲瓣趾腹做改良"V"字形切口,改善拇指指腹外观, 甲瓣切取游离皮瓣修复或人工真皮覆盖修复,定期随访。 结果:I~II度拇指缺损应用改良 甲瓣联合髂骨移植再造拇指,术后供、受区切口一期愈合。术后随访6~24个月,再造手指外形美观,接近健侧拇指,功能良好。指腹感觉恢复S 3~S 4,TPD为6~10 mm。按中华医学会手外科学会上肢部分功能评定试用标准进行评定:优12例,良6例。足部供区保留全部足趾,外形满意,不影响走路跑步,无疼痛等不适感。 结论:甲瓣联合髂骨移植在I~II度拇指缺损全形再造术中临床较为实用,再造拇指外形逼真,感觉、运动功能恢复满意。

目的:探讨应用足底皮肤异位寄养原位回植治疗足部脱套伤的临床治疗效果。方法:2014年3月至2020年1月,应用足底皮肤异位寄养原位回植治疗足部脱套伤5例。足部创面从踝关节以远完全撕脱,创面污染。将全足部撕脱的皮肤分为足背和足底两部分,足背皮肤急诊削薄后一期回植,撕脱足底皮肤修剪成全厚皮移植到大腿前外侧,足底移植皮肤面积18 cm×10 cm~24 cm×13 cm。术后定期门诊随访,观察足部回植皮肤成活情况并定期随访。结果:术后随访5~18个月,术后4例足部回植皮肤全部成活,1例边缘出现部分坏死,术后经清创植皮后痊愈；患肢皮肤回植成活后下地走路足底皮肤耐磨,无破溃,足底感觉麻木,半年后逐渐减轻。结论:足底皮肤异位寄养原位回植治疗足部脱套伤效果满意,临床较实用。

目的:探讨游离腓骨骨皮瓣联合Masquelet膜诱导技术治疗创伤性跖骨缺损的临床效果。方法:2015年8月至2020年6月,应用游离腓骨骨皮瓣联合Masquelet膜诱导技术治疗创伤性跖骨缺损12例。跖骨缺损长度3.2~9.5 cm,截取的腓骨瓣长度4.8~9.5 cm。其中单独第1跖骨缺损5例,同时合并有第2~4跖骨缺损7例。急诊清创后按照Masquelet膜诱导技术操作要求将人工骨水泥填充骨缺损及覆盖肌腱裸露创面,等待约2周后创面分泌物减少、感染初步控制后再行骨与软组织缺损的修复。其中所有第1跖骨骨缺损采取腓骨骨皮瓣移植,将腓动脉与足背动脉吻合4例,2条腓静脉与足背静脉吻合,腓动脉与胫前动脉吻合8例。第2~4跖骨缺损切取自体髂骨植骨术。骨皮瓣供区切取皮瓣宽度不超过5.0 cm直接缝合,宽度大于5.0 cm的、切取全厚皮片游离移植修复。结果:术后门诊随访6~24个月,所有腓骨皮瓣成活,皮瓣外观、色泽正常,质地柔软,无慢性溃疡,术后12周左右骨愈合良好,顺利拆除内固定,步态正常。结论:吻合血管的腓骨皮瓣游离移植修复跖骨缺损,血运丰富、骨愈合速度快,结合Masquelet膜诱导技术抗感染能力更强,有一定的应用价值。

目前随着交通事故的频发,出现越来越多合并臂丛神经损伤的患者,其中以上干损伤多见,临床上表现为伤侧肩外展、外旋、上举和屈肘等功能完全丧失,可造成上肢较高的致残率.神经移位修复损伤神经的部分功能是目前治疗臂丛神经损伤的重要方式[1].膈、副神经移位术是目前临床上常用的治疗上干损伤的手术方法,术后疗效的影响因素一直是临床关注及研究的焦点.2008年至2013年,我院对25例因交通伤致臂丛神经上干损伤的患者行膈、副神经移位术,观察其患肢功能恢复,总结分析可能影响疗效的因素,以期为临床提供参考。

目的探讨臂丛神经损伤外科治疗的手术时机和神经损伤程度的判断与临床疗效的关系。方法 2008年9月至2012年9月我科共收治臂丛神经损伤患者37例,采用的手术方法包括神经松解术、神经修复术、膈/副神经移位术、肋间神经移位术、健侧C7移位术等术式,总结归纳不同手术时机的患者产生的临床疗效。结果 37例均获6个月~1年的随访,功能恢复优良率达70.8%。结论臂丛神经损伤患者确诊后早期行手术治疗及术中对神经损伤的性质、程度的判断对手术疗效有重要的作用。

Objective To compare the efficacy and safety of operation with conservative treatment for acute Achilles tendon rupture. Methods Randomised controlled trials were collected from Medline (from 1966 to March 2012), Embase (from 1966 to March 2012), Cochrane Library (Jan. 2012) and CBM disc (from 1979 to December, 2011), and relevant Chinese and English orthopedic journals. The quality of trials was critically assessed. The rerupture rate, the incidences of complications and wound infection were assessed by using the method recommended by the Cochrane Collaboration. Results (1) The rerupture rate showed no statistically significant difference between open operation and conservative treatment, open operation and percutaneous treatment, postoperative plaster fixation and postoperative functional treatment, conservative plaster fixation and conservative functional treatment. (2) The incidence of complications was significantly lower in conservative treatment and percutaneous treatment than open operation, in postoperative functional treatment than postoperative plaster fixation, but showed no statistically significant difference between conservative plaster fixation and conservative functional treatment. (3) The incidence of wound infection was significantly lower in conservative treatments and percutaneous treatment than open operation, but showed no statistically significant difference between postoperative plaster fixation and postoperative functional treatment. Conclusion For acute Achilles tendon ruptures, open operation results in a lower rerupture rate compared with conservative treatment, but higher incidences of complications and wound infection than percutaneous treatment and conservative treatment. Postoperative functional treatment has a lower incidence of complications than postoperative plaster fixation. Owing to the limits of the quality of the trials, the relation between percutaneous treatment and conservative treatment still needs further study.

肢体其他部位的肿瘤在手部都可以发生,原发于手部的恶性肿瘤除了来源于皮肤之外,来源于其他组织较为罕见,身体一些重要脏器的癌肿可以远距离转移到手部.因此,在讨论手部肿瘤及瘤体样病变时不可避免要注意肿瘤学的一些基本问题,而不仅是骨科学、手外科学的事情.

腕管综合征(CTS)是多种因素所引起的腕管内压力增高使正中神经受压、缺血,表现出相应支配区域的功能障碍,是临床上较为常见的周围神经卡压性疾病.目前,对于中及重型患者主张手术治疗,手术指征的确定主要以患者的临床表现及电生理检测为主,但只能评价正中神经的功能状况,无法反映正中神经及其周围组织结构的变化,且电生理检测结果存在一定程度的假阴性,可对CTS手术指征的选择造成误导作用.本研究拟通过MRI检查,测量计算CTS患者正中神经肿胀率、扁平率,探讨MRI在CTS手术指征中应用的意义,寻找一种客观的评价参数,以期为临床提供参考。

目的探讨腕管综合征的MRI特征及其在临床中的应用价值。方法选取我科2010年1月至2011年12月收治的11例临床确诊为腕管综合征的患者,术前行MRI检查(以横断面为主),手术治疗后探查证实MRI的发现。结果 11例腕管综合征的MRI表现为:正中神经进入腕管时增粗肿胀11例;正中神经肿胀率为(MNSR)2.2:1。正中神经于腕管内受压变扁,正中神经扁平率(MNFR)为3.6%。T2W1正中神经信号增高11例。结论 MRI对腕管综合征的诊断、治疗方式的选择、手术方式的确定具有重要的应用价值。

Objective To compare cosmetic and functional outcome following transfer of posterior tibial artery perforator flaps and sural flaps for reconstruction of foot, ankle and distal lower leg. Methods Fifty-two patients with skin defects of the foot, ankle and distal lower leg from August 2009 to February 2012 were enrolled in this study, of which 25 were treated with posterior tibial artery perforator flaps and 27 with sural flaps. The incidence of postoperative complications were observed, and the leg function of patients was evaluated 6 months after treatment using modified Weber scale. Results Minor flap necrosis (<10%) was observed in 8.7% of the posterior tibial artery perforator flaps and 12.0% of the sural flaps, and partial necrosis (≥10%) was observed in 8.7% of the posterior tibial artery perforator flaps and 4.0% of the sural flaps. Total flap loss only occurred in 2 patients following transfer of sural flaps. Although the mean total score of the modified Weber scale of the posterior tibial artery perforator flaps was lower, but the difference was only significant in the Swelling subscale. Conclusion The incidence of flap necrosis and the morbidity in the donor of the posterior tibial artery perforator flaps was not greater than sural flap, but the former has a better aesthetic. The posterior tibial artery perforator flap should be recommended for reconstruction of small-to medium-sized defects at the foot, ankle and distal lower leg.

Objective To discuss our experience in treatment of posttraumatic radioulnar synostosis. Methods Twenty-one patients with posttraumatic radioulnar synostosis were treated with synostosis resection and interposition of forearm myofascial flap from 2006 to 2012. Results The mean preoperative pronation and postoperative pronation was 14° and 65° before treatment, 5° and 70° after treatment. The patients were followed up for 6~17 months, 11 months in average. The average arc of rotation improved from 15° to 130° . No case of recurrence was found. Conclusion Synostosis resection and interposition with forearm myofascial flap is an effective technique for the treatment of posttraumatic radioulnar synostosis.

Objective To report the clinical effects of the reconstruction for defective fingertip by the proper palmar digital artery flap.Methods Use the lateral direction of the proper palmar digital artery as the flap artery axis and the volaris branches of the proper palmar digital artery as flap artery pedicle.Design the flap on the finger volaris by the recipient area's size and shape.The flap carry only the artery,and the digital nerve stand on it's original position.The pedicle carry with 5.0-1.0mm wide fascia.After flap formation,slightly flex finger,pushforward the flap,and repair of fingertip defect.Repair forefinger fingertip defect in 10 cases,middle finger 6 cases,ring finger 4 cases,little finger 3 cases.Maximum flap was cut 2.5cm × 1.5cm,minimum 1.5 cm × 1cm.Results The flaps were slightly congestive and swelling after operation,but no vascular crisis occurred.23 flaps all survived and the donor site wound surface healed by first intention.All cases were followed up for 6 to 12 months,the texture,thickness,and color of the flaps were similar to original skin of recipient site,non-bloated,wear,finger flexion function were satisfactory,pleasing in appearance,flap point discrimination 10 ~ 15mm,feel good.Conclusion The operation is simple,safe and reliable,the injuries of the donor site are small and can directly suture,surgery can be operated under local anesthesia,the cost is low,and will be helpful for the popularization and application in basic-level hospitals.

Objective To report the clinical effects of micro-titanium plate fixation applied to metacarpal and phalangeal fractures.Methods 40 places of 30 cases of metacarpal and phalangeal fractures had been fixed with micro-titanium plate from October 2005 to February 2010,among them,15 cases with metacarpal fractures(with 18 plates),12 cases with phalangeal fractures(with 13 plates),and metacarpal and phalangeal fractures in 3 cases.Results Postoperative follow-up ranged from 3～12 months,with an average of 6 months.All fractures in this group reached the anatomical reduction and fracture healing was successful,with joint function performing well.Conclusion With the features of light weight,small size,durability,and early rehabilitation training after fixation,micro-titanium plate is an ideal treatment for metacarpal and phalangeal fractures.

目的观察应用肌腱转位治疗前臂缺血性肌挛缩的临床效果。方法对18例前臂缺血性肌挛缩患者采取肌腱移位功能重建。术后石膏固定3周后行功能锻炼。结果 18例患者术后随访1～3年,优6例、良9例、中2例,、差1例、优良率为83.3%。结论通过肌腱移位方法重建前臂缺血性肌挛缩屈指功能,可获得较好效果。

上肢创伤常导致软组织及肌腱缺损,以往治疗一期先行皮瓣修复,3～6个月后二期再行肌腱移植修复术,治疗时间较长。2008年以来,我院对7例腕背复合组织缺损的患者,采用游离股前外侧皮瓣联合足背伸肌腱移植修复术,取得了满意的效果。

Objective To report the treatment options for distal radial fractures.Methods Different treatment methods for distal radial fractures were chosen according to the general classification of Cooney(1990).Manual reduction + gesso external fixation to the stable extra-articular fractures,percutaneous Kirschner wires + gesso external fixation to the unstable extra-articular fractures and stable intra-articular fractures,open reduction + external frame fixation to the extra-articular fractures which closed reduction can not achieved and instable intra-articular or extra-articular fractures after closed reduction,and open reduction + titanium plate fixation + bone graft to the crushing intra-articular fractures were employed respectively.Results All the 60 patients were followed up 8 to 16 months,with the average of 9 months.All the fractures were healed without bone shortening,palm inclination angle changing,infection or traumatic arthritis.According to the wrist joint function and X-ray measurement composite index,38 cases were excellent,17 cases good,5 cases general,and the good to excellent rate was 91.7%.Conclusion As deep understanding of the anatomy and biomechanics of wrist,the treatment of distal radial fractures have been constantly improved.Surgery have better effect to the recovery of fracture anatomic structures and joint function,but also have the risk of hurt or corresponding complications,and increase economic burden.Therefore suitable treatment of distal radial fractures should be selected according to specific situations.

目的 报道应用胫后动脉穿支蒂长轴皮瓣修复内后踝皮肤软组织缺损的临床效果.方法 对内后踝皮肤软组织缺损施行胫后动脉穿支蒂长轴皮瓣修复9例.切取皮瓣面积8 cm×5 cm～4 cm×3 cm.结果 术后9例全部成活,随访6～24个月,皮瓣不臃肿,外观好,功能佳.结论 应用胫后动脉穿支蒂长轴皮瓣修复内后踝皮肤软组织缺损可获得满意的临床效果.

目的 报道应用拇指桡侧指固有动脉背支逆行岛状皮瓣修复指端缺损的手术方法临床效果. 方法 皮瓣设在第1掌骨背侧,以拇指桡侧指固有动脉背支为皮瓣轴.旋转点为近节指骨中部指固有动脉发出背支处,共修复拇指指端缺损20例.切取皮瓣面积最小为1.5 cm×2.0 cm,最大为3.0 cm×4.0 cm. 结果 所有皮瓣全部成活,供区创面Ⅰ期愈合,术后随访6～12个月,皮瓣不臃肿,两点辨别觉为5～7mm,拇指外形功能满意,质地、色泽与正常指相近. 结论 拇指桡侧指固有动脉逆行岛状皮瓣供区靠近创面血供可靠,操作方便,是修复拇指指端缺损的理想皮瓣。