Lai Yeu-Her, Lee Yao-Chou
From the Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
Plast Reconstr Surg Glob Open. 2023 Aug 9;11(8):e5182. doi: 10.1097/GOX.0000000000005182. eCollection 2023 Aug.
Reconstructing a mangled limb is complex and requires expertise in both bone and soft-tissue reconstruction, particularly when there is significant muscle loss. Typically, multistage surgery is necessary, starting with soft-tissue coverage, followed by bone grafting and tendon transfers. Sometimes, microsurgical techniques such as vascularized bone grafts and free functional muscle transfers are necessary, especially when there is a bone defect of over 6 cm; the soft-tissue environment is infected, scarred, or poorly vascularized; or there are extensive musculotendinous injuries. We treated a 34-year-old man who had a crushed left forearm resulting in an 18 × 8 cm open wound, 5-cm radius and 7-cm ulna bone defects, loss of the extensor pollicis longus and brevis muscles, and extensive injuries to the other musculotendinous structures of the forearm. To accomplish a one-stage reconstruction, we used a chimeric fibula osteomyocutaneous flap that included a 20 × 10 cm skin flap, peroneus brevis muscle with its motor nerve, and two segments of fibula. The proximal and distal fibula segments were used for ulnar and radial bone reconstruction, respectively, preserving forearm supination and pronation. The peroneus brevis tendon was sutured to the extensor pollicis longus tendon, and its motor nerve was coaptated with the posterior interosseous nerve to restore thumb extension. The skin flap provided complete coverage of all exposed bone and tendon structures. At the 12-month follow-up, the patient regained full extension of the thumb, and there were no difficulties with forearm supination and pronation or with foot eversion and plantar flexion at the donor leg.
修复严重毁损的肢体是一项复杂的工作，需要骨与软组织重建方面的专业知识，尤其是在肌肉大量缺失的情况下。通常，需要进行多阶段手术，首先是软组织覆盖，接着是骨移植和肌腱转移。有时，诸如带血管蒂骨移植和游离功能性肌肉转移等显微外科技术是必要的，特别是当骨缺损超过6厘米、软组织环境受到感染、形成瘢痕或血运不佳，或者存在广泛的肌腱损伤时。我们治疗了一名34岁男性，其左前臂挤压伤导致一个18×8厘米的开放性伤口、桡骨5厘米和尺骨7厘米的骨缺损、拇长伸肌和拇短伸肌缺失，以及前臂其他肌腱结构的广泛损伤。为实现一期重建，我们使用了一种嵌合腓骨骨肌皮瓣，其包括一个20×10厘米的皮瓣、带有运动神经的腓骨短肌以及两段腓骨。近端和远端腓骨段分别用于尺骨和桡骨重建，保留了前臂的旋后和旋前功能。腓骨短肌腱缝合至拇长伸肌腱，其运动神经与骨间后神经吻合以恢复拇指伸展功能。皮瓣完全覆盖了所有外露的骨和肌腱结构。在12个月的随访中，患者拇指恢复了完全伸展功能，前臂旋后和旋前功能、供区小腿的足外翻和跖屈功能均无困难。
