Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

@xirurgi_2025 - 405 - файл

.pdf

Скачиваний:

Добавлен:

29.08.2026

Размер:

43 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 4 5 6 7 89 / 299 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

2 Anatomy oftheHand andFoot

Fig. 2.69 (a) Morphology and blood supply of exor digitorum brevis. (b) Simulated operation. (1) Flexor digitorum brevis. (2) Plantar fascia. (3) Calcaneus tuberosity. (4) Abductor halluces. (5) Abductor digitorum minimi of toe. (6) Lateral plantar artery. (7) Lateral plantar nerve

vent muscle and skin from slipping. Medial plantar artery should be cut off and ligated and preserve the continuity of posterior tibial arteries, veins and nerves as well as the branches to exor digitorum brevis. The medial plantar vessels are separated from the myoculocutaneous ap, and the vessels between the plantar arch and the lateral plantar vessels should be cut off and ligated at the distal side of the

cutaneous ap is transferred; (2) Lateral plantar artery and medial plantar artery are the blood supply of exor digitorum brevis and its surface skin, and the vascular pedicle is selected as appropriate during the operation; (3) Lateral plantar artery should be carefully preserved in the ap during surgery; (4) When the donor site is too large to be sutured

directly, free skin graft should be used to cover it. myoculocutaneous ap. At this point, the exor digitorum brevis ap with lateral plantar nerve and posterior tibial pedicle is completely dissociated. To cover the recipient site

2.5.6 Abductor Digiti Minimi Flap

with the ap when it is ready. When the donor site cannot be sutured directly, it can be covered with free skin graft.

Abductor digiti minimi supplied by lateral plantar artery is

located on the lateral plantar. Because the lateral margin of

Keypoints forApplication

The following points should be noted in clinic: (1) The nerve branches entering the ap should be protected during the operation to ensure good sensory function after the myoculo-

the foot is involved in weight bearing, it should be used with

caution. Free transplantation can be used to reconstruct the

muscle function thenar and hypothenar and soft tissue defect

of hand.

2.5 Cutaneous (Perforator) Flaps ofToe

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Applied Anatomy

Morphology ofAbductor Digiti Minimi

Abductor digiti minimi is located in the lateral margin of foot, deep surface close to the plantar surface of fth metatarsal, surrounded by supercial plantar aponeurosis, originates from the plantar surface of calcaneus tuberosity, plantar aponeurosis and adjacent intermuscular septum. The starting point is covered by exor digitorum brevis, and the muscle bers move forward to the two short tendons. The lateral tendons reach the trochanter of fth metatarsal, and the medial tendons join with exor digitorum brevis tendon and end at the lateral side of the base of the proximal phalangeal of little toe.

Vasculars ofAductor Digiti Minimi

Most of the arteries (91.37%) are from the branch of lateral plantar artery, and a few (8.63%) are from dorsalis pedis

artery. Along the distance between exor digitorum brevis

and quadratus plantaris, the nerve is divided into two to six

branches along the way, with an outer diameter of 0.2–

0.5mm, to the exor digitorum brevis and the corresponding

skin (Fig. 2.70). Veins of abductor digiti minimi ow into

lateral plantar vein. Each abductor digiti minimi has two to

seven veins with an outer diameter of 0.6 mm.

Nerves ofAbductor Digiti Minimi

The nerves are 60% from lateral plantar nerve, 30% from

medial calcaneal nerve, and 10% from medial plantar

nerve. After the nerve starts, it is externally attached to the

medial side of calcaneus and enters the muscle at the proxi-

mal end of the muscle. The nerve runs through the whole

muscle, and the average length of the nerve trunk is

0.75 cm. The transverse diameter at the starting point is

0.6–1.8mm, and the transverse diameter at the entry point

is 0.4–1.8mm.

Fig. 2.70 Abductor digiti minimi myocutaneous ap. (a) Morphology and blood supply of abductor digiti minimi. (b) Simulated operation. (1) Abductor digiti minimi. (2) Calcaneus tuberosity. (3) Flexor digiti minimi brevis. (4) Lateral plantar artery. (5) Lateral plantar nerve

2 Anatomy oftheHand andFoot

Surgical Methods

A longitudinal incision is made in the lateral plantar nonweight- bearing area. Cut the skin to expose abductor digiti minimi, taking care not to injure lateral plantar artery on the medial side of the muscle. Abductor digiti minimi tendon is cut off near the base of the proximal phalangeal bone of little toe, and the lateral plantar vessels are cut off and ligated at the distal side of the myocutaneous ap, and the proximal branch entering the muscle should be reserved, and exor digiti ap is dissociated. To cover the recipient site with the ap when it is ready. When the donor site cannot be sutured directly, it can be covered with free skin graft.

Keypoints forApplication

The following points should be noted in clinic: (1) More than 90% of the blood supply of the ap comes from lateral plantar artery. The lateral plantar nerve is close to its companion, and the lateral plantar neurovascular pedicle should be the rst choice; (2) Separation of skin and muscle should be prevented when the ap is dissociated.

2.6 Anatomy ofFinger Reconstruction by theToe andJoint toHand Transfer

2.6.1 Thumb Reconstruction by Second Toe Transplantation

Arteries

There are two commonly used blood supply arteries for toe transplantation, which are, “dorsalis pedis artery → rst plantar dorsal artery → dorsal digitorum artery” and “dorsalis pedis artery → deep plantar branch → rst plantar metatarsal artery → proper plantar digitorum artery” (Fig.2.71).

Dorsalis Pedis Artery

Dorsalis pedis artery is a direct continuation of anterior tibial artery (95%), a small number of which originate from the branch of peroneal artery (3%) or from the conuence of anterior tibial artery and the branch of peroneal artery (2%). At the proximal end of rst metatarsal space, it is divided into rst dorsal metatarsal artery and deep plantar branch.

Fig. 2.71 Arterial distribution of great toe and second toe. (a) Cast specimens. (b) Schematic diagram. (1) Dorsalis pedis artery. (2) Arcuate artery. (3) Dorsal metatarsal artery. (4) Anastomotic branch. (5) Dorsal digitorum artery. (6) Tibial plantar digitorum artery of second

toe. (7) Fibular plantar digitorum artery of great toe. (8) Deep plantar branch. (9) First plantar metatarsal artery. (10) Tibial proper plantar digitorum artery of great toe

2.6 Anatomy ofFinger Reconstruction by theToe andJoint toHand Transfer

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Along the way are medial and lateral anterior malleolar arteries, medial and lateral tarsal arteries, and arcuate artery. Dorsalis pedis foot artery is absent or slender (absent less than 1%) in 4.0–6.7%.

Dorsalis pedis artery is often palpable lateral to extensor hallucis longus, which is supercial and covered by extensor hallucis brevis. The length of dorsalis pedis artery is 6.5–8cm and the outer diameter is 2.5 (1.0–3.9) mm.

First Dorsal Metatarsal Artery

After initiation, the accompanying vein and deep peroneal nerve go forward in rst metatarsal space, the vein is supercial, the nerve is middle, and the artery is the deepest. Gilbert classied rst dorsal metatarsal artery into three types (Fig.2.72) according to its depth and branching form

in the path. The occurrence rate of each type is signicantly different in each report, and the comprehensive average is: Type I: 53.5%, rst dorsal metatarsal artery runs the super-

cial surface of interrossei, or is covered with thin layer interrossei at the proximal end.

Type II: 38.5%, rst dorsal metatarsal artery runs in interos-

sei or the deep surface of the muscle.

Type III: 8.0%, dorsal metatarsal artery is small, or absent.

The blood supply of the second toe is the plantar metatarsal artery or planter digitorum artery.

First dorsal metatarsal artery gradually shallowed at the distal end of rst metatarsal space and formed two dorsal digitorum arteries, which, respectively, entered the dorsal subcutaneous side of the opposite edge of great toe and second toe. Another branch near the bifurcation communicated

Fig. 2.72 Gilbert type of rst dorsal metatarsal artery. (1) Dorsalis pedis artery. (2) Deep plantar branch. (3) First dorsal metatarsal artery. (4) First plantar metatarsal artery. (5) Transverse metatarsal ligament

2 Anatomy oftheHand andFoot

Fig. 2.73 The origin type of 1st plantar metatarsal artery

with plantar digitorum artery, and the anastomosis rate is

86.8–100%.

First Plantar Metatarsal Artery

According to Xu Dachuan etal.’s report, there are 4 different types at the beginning of rst plantar metatarsal artery (Fig.2.73).

Type I: Originating from an artery arch of deep plantar

bench and plantar arch accounts for 60%.

Type II: Originating from the continuation of dorsalis pedis artery or an artery arch of deep plantar branch and plantar arch accounts for 30.9%.

Type III, IV: They are the direct continuation of medial and lateral plantar arteries.

The proximal segment of rst metatarsal artery is deep, located under adductor hallucis and near the deep surface of the lateral side of rst metatarsal bone. A typical “X” type artery anastomosis is formed between exor hallucis brevis and the branch of medial plantar artery behind the samoid bone (Fig.2.74).

Blood vessels involved in the formation of an “X” type of cross: The lateral of proximal end is the lateral side of the proximal segment of rst plantar metatarsal artery. The lateral of distal end is the lateral side of the distal segment of rst plantar metatarsal artery: The medial of proximal end is

the branch of medial plantar artery. The meidal of distal end is tibial plantar digitorum artery of great toe.

The distal length of rst plantar metatarsal artery is

3–4cm, and the external diameter of the artery is 1.2 (0.7–

2.4) mm.

Dorsal andPlantar Digitorum Arteries

Dorsal and plantar digitorum arteries have tibial and bular arteries respectively, which are the continuation of dorsal or plantar metatarsal artery respectively and become terminal branch. Plantar digitorum arteries are constant, thick, and are the main blood supply arteries of toes. Only 2%–6% of dorsal digitorum artery is larger than plantar digitorum artery, the external diameter of plantar digitorum artery is 1.1 (0.6–

2.1) mm, and dorsal digitorum artery is 0.6 (0.3–1.2)mm. There are multiple anastomoses between plantar digitorum artery and dorsal digitorum artery, often two to three arterial arches form trafc on dorsum of toe.

Veins

There are supercial and deep veins in the foot and toes. In the deep group, the veins are accompanied by the arteries of the same name, and there are mostly two veins, which are relatively small compared with the arteries. In the supercial group, the veins are thick and rich, but varied in course and

2.6 Anatomy ofFinger Reconstruction by theToe andJoint toHand Transfer

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Fig. 2.74 The course of 1st metatarsal artery and relationship with metatarsal bones and the “X” shaped anastomose

located in supercial fascia. There are extensive anastomotic branches in deep and supercial veins. Dorsal digitorum vein converges at toe wed to form dorsal metatarsal vein, which then joins with the adjacent veins in a network or arched form into great and small saphenous vein. The supercial dorsal foot vein system is used as the venous return system of toe transplantation, which is “dorsal digitorum vein→dorsal metatarsal vein→dorsal venous arch (net)→great saphenous vein” (Fig.2.49).

Nerves

1.Proper plantar digitorum nerve on both the tibial and bular side, which is accompanied by proper plantar digitorum artery. The nerve is located inside the artery. Proper plantar digitorum nerves of great toe, second and third toes are all emitted by common plantar digotorum nerve (a branch of medial plantar nerve).

Announcements

The following points should be noticed in clinic: (1) Incision design should be correct. When there is large soft tissue

defect in the recipient site, ap can be carried on the dorsal side of the toe, skin cannot be used to cover the vascular pedicel, but can be used on the lateral wound. Excess skin should be removed before suturing; (2) When dissociating blood vessels, the unknown direction of the branch should not be easily ligated and cut off; (3) Blood vessels, nerves, tendons, and bones should be measured and severed according to the desired length of the affected area; (4) The subcutaneous tunnel through the vascular pedicle should be spacious to prevent hematoma, so as not to affect the distal blood supply due to vascular compression; (5) Vascular anastomosis ensures quality. One to two more vessels can be anastomosed when conditions are available, such as rst dorsal metatarsal artery plus anastomosis of plantar digitorum artery or plantar metatarsal artery; (6) Minimize the anatomy of plantar pedis as much as possible, pay attention to the repair after toe incision, avoid residual complication of donor site; (7) The blood circulation of the reconstructed nger should be observed closely in the early postoperative period. Once vascular crisis occurs, it should be timely managed. When conservative treatment is ineffective and blood vessel

2 Anatomy oftheHand andFoot

embolism is suspected, exploration should be active and timely. Thrombosis is the most serious complication. If not treated in time, it will eventually lead to necrosis of the transplanted toe; (8) Under the guidance of rehabilitation physician, early systematic treatment, and efforts to restore hand function.

2.6.2 Finger Reconstruction by Second

andThird Toe Transplantation

The arterial and venous pedicles of the second and third toes are the same as that of the single second toe transplantation. The blood supply of the third toe is obtained through the vascular trafc branch between the second and third toes.

Arteries

The blood supply artery of the second and third toes is the same as that of the second toe alone, which has plantar and dorsal systems. There are two commonly used arteries, “dorsalis pedis artery → rst dorsal metatarsal artery → dorsal digitorum artery”, “deep plantar branch of dorsalis pedis artery → rst plantar metatarsal artery → plantar digitorum artery”. The position of plantar digitorum artery and plantar metatarsal artery is constant, and the vessel diameter is large. When rst dorsal metatarsal artery belongs to Gilbert type III or type II b, its anatomical exposure is relatively difcult and complex, and often needs the plantar artery blood supply system, which is also facilitated by common artery or supercial palmar arch on the palm side. There are anastomoses between the trunk and branches of dorsal metatarsal, dorsal digitorum, and plantar digitorum arteries, communicating the blood supply to the two toes and both sides of the toes. There is also artery communication between second and third toe webs. Second dorsal metatarsal artery gives off branches at toe web to communicate the blood supply of second and third toes.

Veins

The vein system of the second and third toes is the same as that of the second toe alone, which is “dorsal digitorum vein→dorsal metatarsal vein→dorsal venous arch (net)→great saphenous vein.”

Nerves

The nerve distribution of the third and second toes is the same.

Announcements

The following points should be noticed in clinic: (1) Strictly indicated, combined transplantation of second and third toes is suitable for patients with total defect of second to fth ngers; Or two to four ngers in the adjacent two ngers in

the proximal phalanx base defect accompanied by the adjacent nger shortage; (2) If two ngers need to be reconstructed, the second toe is cut from each foot to reconstruct, then the foot loss is less, and the foot shape is symmetrical after surgery; (3) Only the anastomosis of rst dorsal metatarsal artery, the second and third toes can survive, but the blood supply of the third toe is insufcient after surgery, so it is appropriate to carry out multi-vessel anastomosis; (4) The repair of lateral tendon bands, lumbricals, and interossei should not be neglected.

2.6.3 Metacarpophalangeal Joints Reconstruction by Second andThird Metatarsophalangeal Joints Transplantation

Applied Anatomy

The Structure ofJoints

The metatarsophalangeal joint is an elliptical joint consisting of the head of metatarsal bone and the base of proximal phalangeal bone. The head of metatarsal bone can be divided into three parts, with the upper one-third facing upward, the middle one-third facing forward, and the lower one-third facing downward. The highest point of articular surface radian is at the junction of the upper one-third and the middle onethird. The articular surface of the proximal phalangeal base is shallow socket. When the joint is at rest, the articular surface of the proximal phalangeal base is in contact with onethird of the articular surface of the metatarsal bone, making the metatarsophalangeal joint in a dorsiexion state. The capsule is attached to the periphery of both articular surfaces. The dorsal articular capsule is loose, with the extensor tendon strengthened, and the collateral ligaments strengthened on both sides. The ligaments start from the nodules on both sides of the metatarsal bone and end obliquely at the base of the proximal phalanges and on both sides of plantar plate. Fibrochondral plantar strengthens on the plantar side of the joint capsule, and the back of plantar plate fuses with the joint capsule, which becomes the expansion part of the joint surface of the proximal phalangeal base. When the toe extends, the plantar plate slid to the distal side, and when the toe exes, the plantar plate slid to the proximal side. The metatarsal surface fuses with the brous sheath of exor digitorum tendon, and together surrounds the brous bone tunnel. The proximal end is thinner, attached to the metatarsal neck, and the distal end is thicker, attached to the metatarsal lip of proximal phalanges, and the two sides are connected with the lateral collateral ligament and the deep transverse ligament of metatarsal bone. Due to the thickness and toughness of plantar plate and the structural characteristics of the articular surface, the exion range of metatarsophalangeal

2.6 Anatomy ofFinger Reconstruction by theToe andJoint toHand Transfer

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

joint is much less than the extension range. Active dorsiextension ranges from 50° to 60°, passive dorsiextension ranges from 85° to 95°, active plantar exion ranges from 30° to 40°, and passive plantar exion ranges from 45° to 55°. It can be seen that metatarsophalangeal joint and metacarpophalangeal joint is similar in morphological structure but completely different in functional activities. The former is mainly dorsiextension, while the latter is exion. These structural and functional differences should be noted during metatarsopalangeal joint transplantation.

Blood Supply ofJoints

Arteries: The blood supply of the metatarsophalangeal joint is rich, including dorsal tibial and dorsal bular branches (three to four branches) from dorsal metatarsal artery, the plantarsal tibial and plantar peroneal branches of plantar metatarsal artery, and the posterior articular artery branches. When each artery reaches the proximal part of the joint, small joint branches with an external diameter of 0.3–0.5mm are formed. The joint branches are anastomosed with each other in the joint capsule to form a joint vascular network. According to its distribution location, it can be divided into joint capsular branches, condyle branches, and metaphyseal branches, which enter the joint within a range of 5mm at the distal and proximal ends of the joint capsule.

Veins: The veins of the joint are accompanied by the arteries of the same name, most of which are two, smaller in diameter than the arteries, and part of which merge into the deep veins accompanying the arteries, but most of which merge into the dorsal metatarsal vein through the trafc branches between the supercial and deep veins, and serve as the main channel of venous return of metatarsophalangeal joint.

Nerves ofJoints

Second metatarsophalangeal joint is supplied by the dorsal branch of deep peroneal nerve and supercial peroneal nerve and the plantar branch of medial plantar nerve. The nerves of third metatarsophalangeal joint are supplied by the dorsal branch of supercial peroneal nerve and the plantar branch of medial plantar nerve. Each joint has about 8–10 branches, with a diameter of 0.3–0.5mm.

Surgical Methods

The surgery is divided into two groups at the same time. One group dissociates the blood vessels, nerves, and tendons in the recipient site, and removed the injured metacarpophalangeal joint to prepare for metatarsophalangeal joint transplantation. Another group dissociates metatarsophalangeal joints.

Cut off the diseased metacarpophalangeal joint: The tourniquet is applied to the proximal arm with a pressure of 40kPa (300mmHg). An “S” shaped incision is made on the dorsal side of metacarpophalangeal joint to expose extensor

digitorum tendon. The tendon cap tissue is cut along the ulnar side of the tendon, and the tendon is retracted radially to expose metacarpophalangeal joint below it. The articular tissues such as the deep transverse ligament of the metacarpal are cut off around the joint capsule, and the disaffected joint is removed with bone knife or electric saw from the metacarpal neck and the base of the proximal phalanx. After arthroplasty, bone of metacarpal and phalanx stump should be normal, without sclerosis of bone stump and stenosis of medullary cavity, so as to avoid bone nonunion after joint transplantation.

Dissociate the vasculars and nerves of the recipient

site: There are two ways to do it: (1) Blood is supplied by

palmar common artery and dorsal palmar vein returns, which should be rst choice when the metacarpophalangeal joint is less injured and there are normal blood vessels for anastomosis. Dorsal palmar vein and dorsal cutaneous nerve of hand can be dissociated in the incision for reserve. Cut the skin and palmar aponeurosis along proximal palmar print or thenar print on the palmar side, and dissociate common palmar digital artery and nerve between exor digitorum tendons to the normal part for use. (2) Blood is supplied by the deep palmar branch of radial artery in snuffbox and cephalic vein returns. A 5cm long oblique incision is made in the snuffbox of the wrist, parallel to the skin margin of rst web space of hand. Cephalic vein and supercial branch of radial nerve are dissociated in the incision, the deep fascia is cut open, and the deep branch of radial artery is dissociated under the tendon. The dissociation length of the blood vessel is about 3cm for use. The subcutaneous tunnel of the two incisions should be opened, and the tunnel should be two transverse ngers wide to avoid compression of the vascular pedicle. When this is done, a tourniquet is released and the bleeding in the wound is stopped completely.

Dissociate metatarsophalangeal joint: Elevate the extremities without exsanguination and apply a tourniquet to the upper thigh at 80kPa (600mmHg) pressure. A “S” shaped incision is made on the dorsal side of metatarsophalangeal joint, with a length of about 10cm. If the recipient site is anastomosed with cephalic vein, it can be dissociated to great saphenous vein; if the recipient site is anastomosed with dorsal metacarpal vein, it can be dissociated to dorsal metatarsal vein. Then cut deep fascia, dissociate dorsal metatarsal artery, type I is supercial, located in the supercial layer of interossei, accompanied by deep peroneal nerve; type II in the space between the bone and interossei, only a small segment within the muscle around the originating point, nd out the artery, on both sides dissociate it sharply, to 1cm proximal metatarsophalangeal joints, pay attention to the branch ligation, the trunk should not be damaged. Deep peroneal nerve is also dissociated from the joint. The branch of the toe is cut and ligated at toe web. At the level of proximal phalangeal osteotomy, the tibial lateral

2 Anatomy oftheHand andFoot

phalangeal artery of the second toe is cut off and ligated, so that the phalangeal artery and dorsal metatarsal artery would be closely connected with the metatarsophalangeal joint, so as to ensure the blood supply of the graft joint. A branch of supercial peroneal nerve to metatarsophalangeal joint is dissociated subcutaneously on the peroneal side. The ligaments around the joint capsule are cut off along the metatarsophalangeal joint capsule, and the exor tendon sheath is lengthways cut on the plantar side to keep plantar plate connected to the joint, and the neurovascular bundle should be connected to the skin on the bular side to ensure the blood supply of the toe. If the recipient site is anastomosed with radial artery, dorsalis pedis artery should be dissociated, extensor tendon should be cut off at the base of metatarsal bone, and dorsalis pedis artery should be found below it. Then, sharp cuts should be made along both sides of the vessels to the desired length. The interossei should be incised at the base of the metatarsal bone, and the deep plantar branches should be cut off and ligated to make dorsal metatarsal artery and dorsalis pedis artery continuous. If dorsalis pedis artery is type III, dissociate plantar metatarsal artery as the pedicle. The metatarsophalangeal joint is truncated with a bone knife or electric saw according to the length of the defect of the recipient site. Release the tourniquet to observe blood supply. In case of a defect of skin and tendon in the recipient site, skin, and tendon grafts can be carried out simultaneously.

Joint transplantation: After the preparation of the recipient site, the blood vessels in the donor site are cut off and the removed metatarsophalangeal joint is inserted into the defect of the recipient site. The metacarpophalangeal joint is xed at the exion position of 20°–30° by using Kirschner wire or cross steel wire. In order to improve the exion of the reconstructed metacarpophalangeal joint, the metatarsophalangeal joint can be rotated 180° along the longitudinal axis, or the broken end of the metatarsal bone can be exed dorsally, and the metatarsal side of the metatarsal bone is made rough surface and relatively xed with the metacarpal bone. But when the metacarpal defect is larger, the second method cannot be used, because it can cause the wrong metacarpophalangeal joint position. If the dorsal hand defect is repaired with dorsal foot skin ap, the metatarsophalangeal joint cannot be rotated, only the second method can be used. If the metacarpal defect is large and the second method is not available, the treatment method is: (1) When the dorsal hand defect is small, carried plantar skin ap for repair, so that the plantar toe joint rotates 180° and the skin ap is just on the dorsal side to repair the dorsal hand defect; (2) When the dorsal hand defect is large, the dorsal foot ap is designed on the proximal end when metatarsophalangeal joint is cut, so that

the skin ap is separated from the joint, which is a series graft, so that after the joint rotated, the ap is still on the dorsal side. If tendons of hand are injuried, can be repaired by toe tendons carried with them.

Reconstruction of blood circulation: In order to prevent blood vessel compression after rotation of joint graft to the recipient site, the contralateral foot should be selected for the graft: (1) If the artery is anastomosed with radial artery, dorsalis pedis artery, great saphenous vein and deep peroneal nerve are led into snuffbox incision through the subcutaneous tunnel. Pay attention to that the vessels in the tunnel should not be twisted or compressed, and the layers are arteries, veins, and nerves in turn. The tension of the blood vessels should be adjusted, and the nerves and vasculars should be nely anastomosed under the microscope; (2) If it is anastomosed with common palmar digital artery, after joint rotation, the artery is on the dorsal side and the vein is on the palmar side. The blood vessels should be extracted through metacarpal space, and attention should be paid to avoid pressure and distortion of the blood vessels. The tension of the blood vessels should be adjusted, and the nerves and vasculars should be nely anastomosed under the microscope.

Postoperative treatment: (1) Blood circulation should be observed according to the requirements of tissue transplantation; (2) Routine microsurgery treatment; (3) Gypsum support should be xed for 6–7 weeks, and passive functional exercise should be begun after Kirschner wire is removed. (4) Tendonolysis should be performed when necessary.

Announcements

The following points should be noted in clinic: (1) Pay attention to the xed position of the graft joint to prevent rotation and angulation deformity; (2) If the ap is carried at the same time for transplantation, the position and size of the ap should be designed to prevent the rotation deformity of the graft joint caused by the wrong position of the ap and the blood circulation crisis of the transplanted tissue caused by the small ap; (3) Preoperative surgery should be carefully designed, and the vascular conditions in the recipient site and donor site should be carefully detected with Doppler, and the blood circulation reconstruction method should be designed according to the vascular conditions. (4) Metatarsophalangeal joint transplantation in children, the epiphysis should be included in to avoid damage, so as not to affect joint development; (5) Note that the diseased bone in the recipient site should be completely removed, otherwise bone nonunion is easy to occur after transplantation. (6) Vascular branches are ligated thoroughly to prevent postoperative bleeding and form hematoma to compress blood vessels.

2.6 Anatomy ofFinger Reconstruction by theToe andJoint toHand Transfer

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

2.6.4 Metacarpophalangeal/Interphalangeal Joint Reconstruction by Proximal Interphalangeal Joint Transplantation ofSecond andThird Toe

Applied Anatomy

The Structure ofJoints

The proximal interphalangeal joint is a trochlear joint composed of the proximal phalangeal trochlea and the base of the middle phalangeal bone. The junction between the upper one-third and the lower two-thirds is separated by a transverse bulge, with the upper one-third facing forward up and the lower two-thirds facing forward down. When the joint is at rest, the articular surface of the phalangeal base is in contact with the lower two-thirds of the articular surface of the trochlea, showing a micro-exion state. The dorsal side of the joint capsule is weak, with extensor digitorum tendon apparatus strengthened, and the lateral collateral ligaments strengthen on both sides. The attachment of the plantar plate is the same as that of metatarsophalangeal joint. The joint can be exed and extended (exion 80°, extension 0°).

Blood Supply ofJoints

Arteries: They are the joint cystic, condylar and epiphyseal branches from dorsal and plantar digitorum arteries, and their distribution is similar to metatarsophalangeal joints. Each branch enters the joint within a range of 1–4mm around the joint capsule.

Veins: Mainly are dorsal digitorum veins.

Nerves ofJoints

They are dorsal digitorum nerves and proper plantar digitorum nerves, mainly are proper plantar digitorum nerves. There are about eight to nine articular branches.

Surgical Methods

The surgery is divided into two groups at the same time. One group dissociates the blood vessels, nerves and tendons in the recipient site, and removed the injured interphalangeal joint to prepare for interphalangeal joint of foot transplantation. Another group dissociates interphalangeal joints of foot.

Cut off the Diseased Interphalangeal Joint: The tourniquet is applied to the proximal arm with a pressure of 40kPa (300mmHg). An “S” shaped incision is made on the dorsal side of metacarpophalangeal joint to expose extensor digitorum tendon. To determine whether to retain, if retained, the base of middle phalanx should be osteotomy in a stepped manner, and the dorsal portion of middle phalanx should be

retained to ensure that the insertion point of extensor digitorum tendon on it is not damaged. Osteotomy is performed in the middle of proximal phalanx, the damaged palmar plate is removed, and the periarticular tissue is cut off around the joint capsule, and the proximal interphalanx joint is amputated. After arthroplasty, bone of metacarpal and phalanx stump should be normal, without sclerosis of bone stump and stenosis of medullary cavity, so as to avoid bone nonunion after joint transplantation.

Dissociate the vasculars and nerves of the recipient

site: There are two ways to do it: (1) Blood is supplied by

palmar common artery and dorsal palmar vein returns. Dorsal palmar vein and dorsal cutaneous nerve of hand can be dissociated in the incision for reserve. Cut the skin and palmar aponeurosis along proximal palmar print or thenar print on the palmar side, dissociate common palmar digital artery and nerve between exor digitorum tendons to the normal part for use. (2) The proper palmar artery is used to supply blood, and the proper palmar artery and nerve are dissociated on the lateral side of nger pulp, and dissociated 2–3cm for use. The dorsal digital vein is dissociated on the dorsal side of the nger, and dissociated 2–3cm for use, to the normal part of the structure and dynamic force. Release the tourniquet to observe blood supply. In case of defect of skin and tendon in the recipient site.

Dissociate interphalangeal joint: Elevate the extremities without exsanguination and apply a tourniquet to the upper thigh at 80kPa (600mmHg) pressure. A “S” shaped incision is made on the dorsal side of interphalangeal joint, with a length of about 10cm. Dissociate dorsal metatarsal vein or dorsal digitorum vein to interphalangeal joint, dissociate the proximal end of the vein according to the required length of the recipient site, then cut open deep fascia, dissociate rst dorsal metatarsal artery, and dissociate interphalangeal joint just like the way dissociating metatarsophalangeal joint. In most cases, only the proper plantar digitorum artery needs to be dissociated, and proper plantar digitorum artery and nerve should be dissociated on the tibial side of the plantar side of the toe, proximal to toe web, and distal to distal interphalangeal joint, and then cut and ligated. Dissociate the joint along the joint capsule and pay attention to not damage the peroneal blood vessels, to ensure the blood supply of the distal toe. The interphalangeal joint is truncated with a bone knife or electric saw according to the length of the defect of the recipient site. Release the tourniquet to observe blood supply. In case of a defect of skin and tendon in the recipient site, skin and tendon grafts can be carried simultaneously.

Joint transplantation: After the preparation of the recipient site, the blood vessels in the donor site are cut off and the removed metatarsophalangeal joint is inserted into the defect

<<< < Предыдущая 1 2 3 4 5 6 7 89 / 299 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

Соседние файлы в папке @xirurgi_2025

#
29.08.202644 Мб0@xirurgi_2025 - 396 - файл.pdf
#
29.08.202644 Мб0@xirurgi_2025 - 398 - файл.pdf
#
29.08.202643 Мб0@xirurgi_2025 - 401 - файл.pdf
#
29.08.202643 Мб0@xirurgi_2025 - 402 - файл.pdf
#
29.08.202643 Мб0@xirurgi_2025 - 404 - файл.pdf
#
29.08.202643 Мб0@xirurgi_2025 - 405 - файл.pdf
#
29.08.202643 Мб0@xirurgi_2025 - 406 - файл.pdf
#
29.08.202642 Мб0@xirurgi_2025 - 409 - файл.pdf
#
29.08.202642 Мб0@xirurgi_2025 - 411 - файл.pdf
#
29.08.202641 Мб0@xirurgi_2025 - 412 - файл.pdf
#
29.08.202641 Мб0@xirurgi_2025 - 414 - файл.pdf