Türker ÖZKAN, Fatih KABAKAŞ, Atakan AYDIN, Bülent YAPRAK, Eftal GÜDEMEZ

Elin duyu restorasyonu için pediküllü flep uygulamaları ve geç dönem sonuçlar

Amaç: Elde duyu ve yumuşak doku restorasyonu için pediküllü fleplerle onarım yapılan hastaların geç dönem sonuçları değerlendirildi. Çalışma planı: Çalışmaya 30 hasta (26 erkek, 4 kadın; ort. yaş 33; dağılım 16-62) alındı. Yirmi dört hastada başparmak, üçünde işaret parmağı, üçünde beşinci parmak ulnar taraf duyu restorasyonu yapıldı. Yirmi yedi hastada damarlı ve sinirli ada flebi, üç hastada duyulu çapraz parmak flebi kullanıldı. Onarımda damarlı ve sinirli ada flebi kullanılan hastaların 11’inde sinir ayırma ve tekrar birleştirme tekniği uygulandı. Duyu değerlendirmesi Semmes-Weinstein monofilaman testi ve iki nokta ayrım testiyle yapıldı. Ortalama izlem süresi 29.2 ay (dağılım 5-144 ay) idi. Sonuçlar: Hiçbir hastada flep kaybı gözlenmedi. Damarlı ve sinirli ada flebi uygulanan dört hastada (%14.8) donör parmaklarda kontraktür oluştu. Ayırma-tekrar birleştirme yöntemi uygulanan iki hastada (%18.2) tenar alanda nöroma oluşumu gözlendi. Statik ve hareketli iki nokta ayrım testleri, ayırma-tekrar birleştirme yapılan hastalarda sırasıyla ortalama 9.1 mm ve 7.4 mm, orijinal tekniğin uygulandığı hastalarda 8.3 mm ve 7 mm, duyulu çapraz parmak flebi uygulanan hastalarda ise 10.3 mm ve 8.6 mm olarak ölçüldü. Ayırma-tekrar birleştirme yapılan tüm hastalarda duyu lokalizasyonu alıcı sahada algılandı. Orijinal tekniğin uygulandığı 16 hastanın dokuzu (%56.3) duyuyu alıcı sahada lokalize ederken, üçü (%18.8) verici sahada algıladı. Dört hastada (%25) ise çapraz duyarlılık gözlendi. Çıkarımlar: Pediküllü flepler, parmaklarda hem yumuşak doku hem de duyu restorasyonu açısından oldukça güvenilir ve tatminkar seçeneklerdir. Ayırma-tekrar birleştirme işlemi çapraz duyarlılığı engellemek açısından oldukça başarılıdır.

Anahtar Kelimeler:

Cerrahi flepler, Duyu, Rekonstrüktif cerrahi işlemler, El parmağı yaralanmaları, El parmakları, Sinir dokusu, El baş parmağı, Tedavi sonucu

Pedicled flap procedures for sensory restoration of the hand: long-term results

Objectives: We evaluated the long-term results of patients who underwent reconstruction with pedicled flaps for soft tissue and sensory restoration. Methods: The study included 30 patients (26 males, 4 females; mean age 33 years; range 16 to 62 years) who underwent sensory restorations of the thumb (n=24), the index finger (n=3), and the little finger (n=3). Twenty-seven patients received neurovascular island flaps and three patients received radial innervated cross-finger flaps. Disconnectionreconnection of the nerve was performed in 11 patients receiving a neurovascular island flap. Sensory evaluations were made with two-point discrimination and the Semmes- Weinstein monofilament test. The mean follow-up was 29.2 months (range 5 to 144 months). Results: There were no cases of flap loss. Contractures of donor digits were seen in four patients (14.8%) treated with neurovascular island flaps. Neuroma formation was noted in two patients (18.2%) in whom the disconnection-reconnection technique was used. Static and moving two-point discrimination test results were 9.1 mm and 7.4 mm with the disconnection- reconnection technique, 8.3 mm and 7 mm with the original technique, and 10.3 mm and 8.6 mm with radial innervated cross finger flaps, respectively. Sensation was at the recipient site in all the patients who underwent disconnection- reconnection. Of those in whom the original technique was employed, nine patients (56.3%) localized sensation at the recipient site, three patients (18.8%) at the donor site, while four patients (25%) showed double sensibility. Conclusion: Pedicled flaps are reliable and satisfactory alternatives for soft tissue and sensory restoration of hand injuries and disconnection-reconnection of the nerve is effective in preventing double sensibility.

Keywords:

Surgical Flaps, Sensation, Reconstructive Surgical Procedures, Finger Injuries, Fingers, Nerve Tissue, Thumb, Treatment Outcome,

PDF

___

1. Swanson AB, Hagert CG, Swanson GD. Evaluation of impairment of hand function. J Hand Surg [Am] 1983;8(5Pt 2):709-22.
2. Tubiana R, Duparc J. Restoration of sensibility in the hand by neurovascular skin island transfer. J Bone Joint Surg [Br] 1961;43:474-80.
3. Litter JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J Bone Joint Surg [Am]1956;38:917.
4. Ozkan T, Ozer K, Gulgonen A. Restoration of sensibility in irreparable ulnar and median nerve lesions with use of sensory nerve transfer: long-term follow-up of 20 cases. J Hand Surg [Am] 2001;26:44-51.
5. Foucher G, Braun FM, Merle M, Michon J. The “disconnecting- reconnecting” technique of the neurovascular island pedicle flap. Ann Chir 1981;35:303-3. [Abstract]
6. Holevich J. A new method of restoring sensibility to the themb. J Bone Joint Surg [Br] 1963;45:496-502.
7. Paneva-Holevich E, Holevich Y. Further experience with the bipedicled neurovascular island flap in thumb reconstruction. J Hand Surg [Am] 1991;16:594-7.
8. Gaul JS Jr. Radial-innervated cross-finger flap from index to provide sensory pulp to injured thumb. J Bone Joint Surg [Am] 1969;51:1257-63.
9. Hastings H 2nd. Dual innervated index to thumb cross finger or island flap reconstruction. Microsurgery 1987;8:168-72.
10. Ogun TC, Ozdemir M, Senaran H, Ustun ME. End-to-side neurorrhaphy as a salvage procedure for irreparable nerve injuries. Technical note. J Neurosurg 2003;99:180-5.
11. Buncke HJ, Rose EH. Free toe-to-fingertip neurovascular flaps. Plast Reconstr Surg 1979;63:607-12.
12. Adani R, Squarzina PB, Castagnetti C, Lagana A, Pancaldi G, Caroli A. A comparative study of the heterodigital neurovascular island flap in thumb reconstruction, with and without nerve reconnection. J Hand Surg [Br] 1994;19:552-9.