岛状趾甲在巨趾症治疗中的应用

MD.Yang Wang Department of Hand and Foot Surgery, The Second Hospital of ShanDong University; The Orthopaedic Foot & Ankle Center.山东大学第二医院手足外科 汪洋,Island Nail Transfer in the Treatment of Macrodactyly,The first known series on pedal macrodactyly was published in 1925 by FerizRegardless the etiology, Barsky defined two primary clinical types of macrodactyly: static (present at birth, but increases proportionally with the other digits) and progressive (size increases at a disproportionately higher rate compared with the other digits). Feriz H. Macrodystrophia lipomatosa progressiva. Virchows Arch Pathol Anat Physiol Klin Med 1925; 260:308368.Barsky AJ. Macrodactyly. J Bone Joint Surg Am 1967; 49:12551266.,A number of treatment options have been proposed without consensus; specific treatment for pedal macrodactyly is on an individual basis. The primary goal of treatment is to produce a pain-free, functional foot that can accommodate normal shoes; in addition, the cosmetic appearance of the foot, and particularly the nail, is of great concern to the patient and family.Hop MJ, van der Biezen JJ. Ray reduction of the foot in the treatment of macrodactyly and review of the literature. J Foot Ankle Surg 2011; 50:434438.Natividad E, Patel K. A literature review of pedal macrodactyly. Foot Ankle Online J 2010; 3:25.,Pedal macrodactyly is often of the progressive variety. There is generally a slight male majority. Preaxial distribution is predominant, with the second digit being the most common. More than one digit may be involved, and in 10% of cases, there may be syndactyly involving an adjacent digit.Kumar K, Kumar D, Gadegone WM, Kapahtia NK. Macrodactyly of the hand and foot. Int Orthop 1985; 9:259264.Dennyson WG, Bear JN, Bhoola KD. Macrodactyly in the foot. J Bone Joint Surg Br 1977; 59:355359.Natividad E, Patel K. A literature review of pedal macrodactyly. Foot Ankle Online J 2010; 3:25.Krengel S, Fustes-Morales A, Carrasco D, Vazquez M, Duran-McKinster C, Ruiz-Maldonado R. Macrodactyly: report of eight cases and review of the literature. Pediatr Dermatol 2000; 17:270276.Tsuge K. Treatment of macrodactyly. J Hand Surg Am 1985; 10:968969. Kotwal PP, Farooque M. Macrodactyly. J Bone Joint Surg Br 1998; 80: 651653.,Treatment options include, but are not limited to, debulking/ablation of fat and other hypertrophied tissues; epiphyseodesis or physeal resection; reduction syndactyly; assorted osteotomies (including phalangeal shortening, and interphalangeal and metatarsophalangeal joint resections); interphalangeal and metatarsophalangeal joint arthrodeses; phalangectomy (particularly middle phalangectomy); amputation (various levels); and ray resection; numerous combinations are also utilized.,INDIA 1998,The Tsuge procedure for pedal macrodactyly,(a) A fish-mouth incision is made to the level of the proximal phalanx;(b) the flexor and extensor tendons are released from the distal phalanx. A transverse osteotomy is made in the distal phalanx to remove the distal phalangeal physis. A coronal osteotomy is made to preserve the dorsal one-third of the distal phalanx. A similar coronal osteotomy is made preserving the plantar two-thirds of the middle phalanx; a transverse osteotomy is made in the proximal portion of the dorsal one-third of the middle phalanx to preserve the middle phalangeal physis.,(c) The dorsal one-third of the distal phalanx is fixed to the plantar two-thirds of the middle phalanx and the tendons are reattached. A large amount of fibrofatty tissue remains plantarly. (d) Excess tissue is debulked and the is wound closed. There is often a dorsal bump created.,(a) Intraoperative coronal osteotomy of the distal phalanx. The dorsal one-third of the distal phalanx is kept, preserving the nail matrix and plate.(b) The physis (which is now visible) is removed by transverse osteotomy from the remaining dorsal bone. The plantar portion is removed.,A large amount of plantar fibrofatty tissue remains when the digit isshortened. A dorsal bump is typically created on shortening the digit.,(a) Preoperative and (b) postoperative appearance of macrosyndactylous digits reconstructed according to the Tsuge procedure.,A typical course in the Tsuge procedure for pedal macrodactyly. (a) Preoperative appearance. (b) Postoperative appearance of the foot following theTsuge procedure: 6 weeks postoperatively for fourth toe and 6 months postoperatively for the third toe. Dried blood is common at the suture line.(c) Appearance of the third and fourth toes of a foot more than 6 years after the Tsuge procedure. A normal toe cascade has been maintained.,Radiographs corresponding to Fig. 5. (a) Preoperative and (b) postoperative radiographs 6 weeks after reconstruction of the fourth toe and 6 monthsafter reconstruction of the third toe. (c) Radiographs obtained 6 years postoperatively. The osteotomies are healed without angular deformity.,Although later resection of the bump was described as a part of the Tsuge procedure, in our series, the dorsal skin bump had resolved such that no child considered it to be an issue. Whereas amputation is more often recommended for the progressive type of macrodactyly, in our series, the Tsuge procedure proved useful in both static and progressive types of macrodactyly.Barsky AJ. Macrodactyly. J Bone Joint Surg Am 1967; 49:12551266.Tsuge K. Treatment of macrodactyly. Plast Reconstr Surg 1967; 39:590599.,island-nail transfer,Fig. 1 Case 1: Preoperative radiographs (a) and planned incisions (b). Note the hatched area where the ap was to be transferred,Fig. 2 Case 1: Intraoperative images. a Dissection of the nail ap.b Longitudinal osteotomy of the distal phalanx. Note the vessel loopprotecting the neurovascular bundle,Fig. 3 Case 1: Final immediate postoperative result showing adequate perfusion of the toe,Fig. 4 Case 1: Clinical photograph (a) and radiograph (b) at 15 months follow-up,Fig. 5 Case 2: Initial clinical photograph (a) and radiograph (b),Fig. 6 Case 2: Clinical photograph (a) and radiograph (b) at 1-year follow-up,The deformity is often progressive with less neural involvement than in hand macrodactyly There is no clear time at which it is best to perform surgery. We think that surgery should be done when shoe wear is difficult or impossible or the foot has become cosmetically unacceptable.There is general consensus that when the first ray is not affected, the best option is to carry out a complete ray resection.,FIGURE 1 (A) Preoperative photograph of the affected right foot. (B) Preoperative anteroposterior radiograph of the foot. Note the markedincrease in size and length of the hallux.,FIGURE 2 Incisional prole of the nail ap. (A) Dorsal view. Note the longitudinal incision through the nail plate on the medial side of thetoe to allow for reduction of the nail width. (B) Plantar view. The hatched area corresponds to the amount of pulp and plantar tissues thatwould be resected.,FIGURE 3 Dissection of the nail island ap. (A) The plantar and lateral collateral artery of the rst toe is visible over the tip of the microscissors. This artery would provide blood inow to the nail ap. (B) Subcutaneous tissues over the proximal phalanx contain the dorsaldraining vein of the nail.,FIGURE 4 Final steps of the dissection, showing the nail island ap in its new position. (A) The medial slip of pulp ready to cover the tipof the shortened toe. (B) Nail and medial slip are in their nal positions. The skin hook contains the pulp and plantar tissues to be resected.,FIGURE 5 Intraoperative photograph after release of the tourniquet, showing adequate blood supply of the nail and remaining toe.,FIGURE 6 One-year follow-up. (A) Clinical photograph of the foot. (B) Anteroposterior radiograph.,a vascularised nail graft,Figure 1 Preoperative ndin