(文接上期) 3讨论 手作为人类生产、生活的主要工具,是最常受伤的部位之一.随着工业化进程,目前临床各种严重手外伤较为常见,且常合并神经、血管、肌肉肌腱、皮肤软组织及骨缺损.其中骨缺损的重建是手外科与显微外科治疗、研究的热点及难点.骨缺损即骨骼结构完整性被破坏,分为容积性骨缺损和结构性骨缺损.

目的 探讨胫后动脉穿支"螺旋桨"皮瓣修复老年踝关节骨折术后踝内侧软组织缺损的临床疗效.方法 回顾性分析2016年11月-2021年2月收治的踝关节骨折术后踝内侧软组织缺损8例老年患者临床资料.术前采用彩色超声多普勒定位穿支血管情况,设计并切取胫后动脉穿支"螺旋桨"皮瓣修复创面.切取皮瓣面积:6.0 cm ×10.0 cm～8.0 cm×15.0 cm.术后观察皮瓣的成活、外观、质地、感觉、并发症及供区情况;同时对术前及末次随访时运用美国足踝外科协会(AOFAS)踝-后足评分系统评价的足部功能结果进行比较,评分结果均采用统计学方法进行统计分析.结果 28例中,供区一期缝合15例,植皮13例;25例皮瓣全部成活,3例皮瓣出现部分坏死(皮瓣远端1/3～1/4坏死),经清创、负压封闭引流(VSD)、植皮、换药处理后均得到良好愈合.28例均获随访,随访时间6～24个月,平均10.5个月.皮瓣色泽可、质地柔软、外观满意,皮瓣恢复保护性感觉,4例术后供区瘢痕增生明显,皮瓣周围无瘢痕挛缩.踝关节伸、屈功能根据骨折类型的不同,出现不同程度活动受限,末次随访时采用美国足踝外科协会(AOFAS)踝-后足评分系统评定为(90.9±4.8)分,与术前(72.7±1.9)分比较差异有统计学意义(t=18.357,P＜0.001);优20例,良5例,差3例,优良率为89.2％.结论 老年患者踝关节骨折术后容易出现软组织缺损,应用胫后动脉穿支"螺旋桨"皮瓣修复操作简单、可靠,是修复此类损伤较好的方法之一.

目的 探讨肱骨髁上截骨联合外固定支架辅助复位固定治疗儿童肘内翻的临床方法及效果.方法回顾性分析2018年5月-2019年5月采用肘关节外侧小切口,肱骨髁上楔形截骨联合外固定支架骨钉作为操作杆进行复位固定,治疗20例儿童肘内翻的临床资料.术后均采用肘关节功能位石膏托固定,4周后拆除石膏进行功能训练.结果 所有患儿术后随访2～3年,截骨部位均于术后6～8周骨性愈合,术后2～3个月肘关节屈伸活动范围恢复正常.术后提携角由术前平均内翻30.恢复至术后平均外翻10°,肘内翻畸形无复发.结论 肱骨踝上楔形截骨术后,在截骨平面的远近端采用外固定支架的骨钉作为操作杆进行复位固定,治疗儿童肘内翻,具有切口小、操作简单、截骨角度准确、复位简单等优点,同时可一次性矫正尺偏、过伸、旋转畸形,固定牢固.该手术方法可以实现患儿早期的肘关节功能训练,加快关节活动度的恢复.

目的 探讨应用Mini Ilizarov外固定支架治疗大龄儿童先天性并指畸形的临床效果.方法 采用回顾性方法选取2019年1月至2021年11月该院收治的采用Mini Ilizarov外固定支架治疗的大龄儿童先天性并指畸形患儿7例,均为中环指先天性并指,其中单纯性完全并指5例,普通复杂并指2例.采用Mini Ilizarov外固定支架牵张对皮肤扩容,4周后二期并指分指,按总主动活动度标准评定手功能.术后通过门诊复查、网上发送图片、电话询问3种方式随访3～12个月,中位6.8个月.结果 7例并指畸形均分指成功,未植皮,外观、功能满意,效果好.分指手指瘢痕不明显,无瘢痕增生.结论 应用Mini Ilizarov外固定支架治疗大龄儿童先天性并指畸形效果满意,不需要植皮,值得临床推广应用.

OBJECTIVE:To evaluate the effectiveness of the nose ring drain (NRD) in treatment of severe diabetic foot infection. METHODS:The clinical data of 35 patients with severe diabetic foot infection who were treated with NRD between June 2017 and June 2019 were analyzed retrospectively. There were 24 males and 11 females with an average age of 54.5 years (range, 28-82 years). All of them were type 2 diabetic patients. The diabetes duration was 3-20 years, with an average of 9.4 years. The diabetic foot duration was 4 months to 2 years, with an average of 1.16 years. There were 16 cases of left foot and 19 cases of right foot. According to Wagner's grading, there were 11 cases of grade 2, 20 cases of grade 3, and 4 cases of grade 4, all of which were moderate and severe infection of diabetic foot wound. Postoperative wounds were treated with "nibble-like" debridement until the patient's epidermis regenerated and healed. During the treatment process, the indexes of bacterial culture type of wound secretions, duration of antibiotic therapy, wound healing method, healing time, amputation rate, and other indicators were analyzed and summarized. RESULTS:All 35 patients were followed up 3-6 months, with an average of 4.5 months. Postoperative bacterial culture of wounds showed that 5 cases of Staphylococcus aureus, 4 cases of Pseudomonas aeruginosa, 5 cases of Escherichia coli, 3 cases of Enterobacter cloacae, 3 cases of coagulase-negative Staphylococcus, and 15 cases of other types were detected. The duration of antibiotic therapy ranged from 3 to 15 days, with an average of 9.1 days. The wound was autolytically healed without skin grafting, and the healing time was 62-82 days, with an average of 72.3 days. During the follow-up, 3 cases (8.6%) had amputation due to the patient's poor blood glucose control, which led to a large spread of infection. In addition, among the other patients with wound healing, there was no recurrence of wound infection or new ulcer on the original surface. CONCLUSION:The NRD is a simple operation for treatment of severe diabetic foot infection, which can effectively control wound infections and promote wound healing and regeneration without skin grafting.

目的 总结吻合血管再植治疗完全离断耳廓伤8例的体会.方法 回顾性分析8例不同平面耳廓完全离断伤通过吻合血管再植成功病例,8例术中予吻合1～2条动脉,1～3条静脉,均一次性通血成功.术后予镇静、密切观察血液循环.结果 8例耳廓离断再植术后Ⅰ期全部成活,术后随访1.5～31个月,平均10.8个月.7例耳廓保护性感觉恢复,生活质量获得显著改善,未遗留明显心理障碍.结论 耳廓血管薄、管腔细小,但其血供丰富.再植操作技术要求高,摆位困难,手术难度相对较大,但只要争取吻合血管,并保证吻合质量,成功几率较大.吻合血管再植是耳廓离断伤的首选治疗方法.

Objective:To summarize and analyze the surgical method and clinical efficacy of Mini Ilizarov external fixation in the treatment of open comminuted phalangeal fractures.Methods:From June 2019 to November 2019, 31 patients with open comminuted phalangeal fractures were treated with Mini Ilizarov external fixation. All of them were emergency operations. According to the recovery of the patients, the finger function exercise was performed step by step, and the fracture healing time and the total active motion (TAM) of metacarpophalangeal joint and interphalangeal joint were recorded.Results:All the patients were follow-up for 3 to 6 months with an average of 4.5 months. All the fractures achieved clinical healing, including 3 cases (9.7%) with needle tract infection which recovered after symptomatic treatment, 2 cases (6.4%) with joint stiffness and 1 case (3.2%) with 4 ° rotation malunion. According to TAM standard, 24 cases were excellent, 4 cases were good and 3 cases were fair. The excellent and good rate was 90.32%.Conclusion:Mini Ilizarov external fixation in the treatment of open comminuted phalangeal fractures can effectively improve the fracture healing rate and promote the early functional exercise of the affected limb. It is one of the recommended methods for the treatment of open comminuted phalangeal fractures.

Objective To access the clinical utility of miniature free Flap to repair multi-digit soft tissue defect. Methods From June 2015 to June 2017, 9 cases of soft tissue defect in 26 digits were treated with multiple miniature free flap reconstructions, including 2 digits defect in 3 cases using bilateral fibular flap of the toe, 3 digits defect in 4 cases using bilateral fibular flap of the toe plus uniliateral medial pedal flap and 4 digits in 2 cases using bilateral fibular flap of the toe plus biliateral medial pedal flap. The doner site were directly closed in all cases. Results All flaps survived postoperatively without vascular crisis. Donor and recipient sites healed by first intention. With a mean follow-up of 18 months (ranged 3～24 months), all free flaps appeared to be in good texture, elasticity and aesthetics. According to CMAHS upper extremity scoring system, postoperative hand function were rated excellent in 21 cases, good in 4 cases and poor in 1 case. Static 2 point discrimination was 7.5 mm (ranged 6 mm～9 mm). Conclusion We can achieve a satisfactory long -term aesthetic and functional outcome of multiple digital soft tissue reconstruction using miniature free flap.

随着交通工具、各类机械(电梯、电扶梯等)在我们日常生活中的广泛应用,机械损伤事故发生率在急速攀升.其中由于儿童监护人安全意识缺乏、警觉性差造成的儿童机械性损伤事故正在成为威胁儿童生命安全、造成儿童严重受伤致残致死的最大隐患.这些在日常生活中无处不在的机械设施已经成为造成儿童意外事故或意外死亡的直接原因之一.我国每年有上千万儿童因意外事故而受伤或致残,其中低龄儿童所占比例也在不断增加[1,2].

患者男，18岁，于2015年2月2日因双手被切割机切断后疼痛、出血1h入院。查体：左手示、中、环指及右手示指从中节完全离断（右示指 DIP 关节离断），右手中、环、小指从近节离断，近、远端离断指体污染轻，创缘较整齐（图1～4）。

Objective To report clinical outcomes in the treatment of infected soft tissue defects in the heel by peroneal artery perforator flap transfer. Methods From January 2011 to June 2013, infected soft tissue defects in 13 heels were treated by peroneal artery perforator flaps, among which 1 flap carried small saphenous vein and sural nerve. Before the transfer of the flap, infected heels had debridement followed by vacuum sealing drainage ( VSD ) and irrigation with sensitive antibiotic solution until the wound presented with a negative bacterial culture. Results All the 13 flaps survived completely. A follow-up of 3-24 months revealed that the flaps transferred onto the heels had good color without scar contracture, ulceration or sinus. Flaps regained basic protective sensation 12 months after operation. American Orthopaedic Foot and Ankle Society ( AOFAS ) scoring system was used to evaluate the ankle function ( good-excellent rate: 84.6% ): excellent in 8 cases, good in 3, fair in 1, poor in 1. Conclusions Transfer of a peroneal artery perforator flap after debridement and VSD in the recipient wound is an effective method in the treatment of infected heel soft tissue defect.

目的 报道应用指动脉终末背侧支岛状皮瓣修复手指甲根平面以远皮肤软组织缺损的手术方法.方法 对19例指端甲根平面以远皮肤软组织缺损者,采用指动脉终末背侧支岛状皮瓣转移修复创面,前臂取皮供区植皮术.结果 术后19例皮瓣中,18例顺利成活,1例部分坏死,给予换药后完全愈合,供区植皮全部成活.随访2～15个月,皮瓣外观、功能、质地满意,浅感觉存在,深感觉较差.结论 指动脉终末背侧支岛状皮瓣是修复指端甲根平面以远皮肤软组织缺损的理想手术方式.