两种静脉动脉化再植断指的比较

Comparison of two methods of veno-arteriolization for replantation of severed fingers

目的通过与传统单式静脉动脉化再植的比较,探讨双动脉式静脉动脉化再植断指的可行性及疗效。方法选取2008年2月—2012年10月收治并符合选择标准的40例（40指）断指患者纳入研究,均在正常指动脉多次吻合失败后行静脉动脉化。将患者随机分为两组,试验组（n=20）：采用双动脉式静脉动脉化再植,将非优势侧指动脉近端端侧吻合于优势侧指动脉上,然后再将优势侧动脉的近端与远端静脉吻合（近、中节断指选指掌侧静脉,末节断指选指侧方静脉）;对照组（n=20）：采用单式静脉动脉化再植,直接将优势侧指动脉近端与远端静脉吻合。两组患者性别、年龄、致伤原因、病程、损伤指别、指分型、动脉吻合失败次数及骨折、神经损伤比较,差异均无统计学意义（P〉0.05）,具有可比性。结果试验组病例全部成活,创面均Ⅰ期愈合;对照组5例坏死。33例获随访,随访时间6-14个月。试验组19例指外形佳、指腹饱满,指体无明显萎缩;指甲生长平整,长度（15.4±2.2）mm,长于对照组（P〈0.05）;两点分辨觉（4.8±0.3）mm,小于对照组（P〈0.01）;指关节活动度（86±5）°,大于对照组（P〈0.05）;感觉测定为S2-S4,平均为S3＋,高于对照组（P〈0.05）;参照Tamai评分标准：优15例,良4例,优良率100%,两组优良率差异有统计学意义（χ2=8.420,P〈0.05）。对照组14例（坏死指除外）指体轻度萎缩。指甲生长不平整,长度（11.5±2.0）mm;两点分辨觉（7.6±0.4）mm;指关节活动度（65±3）°;感觉测定为S2＋S3＋,平均为S2;参照Tamai评分标准：优7例,良4例,可3例,优良率78.6%。结论双动脉式静脉动脉化放大了单式静脉动脉化作用,迅速使瓣膜无创伤性失效,有效灌注多,明显提高再植指成活率,促进指甲生长及感觉恢复,增强指关节活动度,为正常方法失败后提供了一种更有效的补救方法。

Objective To explore the feasibility and effectiveness of veno-arteriolization of bilateral proper digital artery for repairing severed fingers by comparing with traditional veno-arteriolization of single proper digital artery. Methods Forty quafified patients with severed fingers （40 severed fingers） who were admitted from February, 2008 to October, 2012 were selected. They aU received veno-arterlollzation after failing to anastomose arteries of finger for several times. Patients were randomly divided into two groups, i.e. the trialgroup （ n =20） and control group （ n =20）. Patients of the trial group underwent veno-arteriolization of bilateral proper digital artery. The proximal non-superiorty digital artery was anastomosed to the dominant digital artery and then the proximal dominant digital artery was anastomosed to the distal digital vein （palmar vein for replantation of proximal or middle segment of finger and lateral vein for replantation of distal segment of finger）. Patients of the control group underwent veno-arteriolization of single proper digital artery. The proximal dominant digital artery was directly anastomosed to the distal digital vein. The differences of gender, age, cause of injury, duration of disease, injured finger, lesion segments, failure times of anastomosing artery of finger, fracture, and nerve damage of two groups were not statistically significant （P〉O. 05） and comparable. Results Replanted fingers of all patients of the trial group were survived and achieved pnary healing. Five replanted fingers of the control group necrotized. And 33 patients were successfully followed up for 6 to 14 months. Replanted fingers of 19 patients of the trial group had satisfactory appearance. The finger pulp was plump with good flexibility and the finger body did not atrophied significantly. The nail of the trial group grew evenly and the length of nail was （15.4 ±2.2） mm, which was significantly longer than that of the control group （P〈 0.05）. The two point discrimination was （4. 8 ±0.3） mm and was significandy shorter than that of the control group（P〈0.01）. The motion of joint was （86 ±5）± and was significantly higher than that of the control group （P〈O. 05）. The sensation measurement was S2 -S4 and the average of which was S3 ＋, which was significantly higher than that of the control group （P〈0. 05）. According to the Tamai＇s classification, the results of 15 cases were excellent and 4 cases were good. The rate of excellent and good results was 100%. The difference of the rate of excellent and good results of two groups was statistically significant （x2 =8.420, P〈O. 05）. Finger bodies of 14 patients of the control group （ except necrotic fingers） mildly atrophied. The nail grew unevenly and the length of nail was （11.5 ±2.0） mm. The two point discrimination was （7.6 ±0.4） mm. The motion of joint was （65 ±3） °. The sensation measurement was S2 -S3 ＋ and the average of which was S2. According to the Tamal＇s classification, the results of 7 cases were excellent; 4 cases were good; and 3 cases were fair. The rate of excellent and good results was 78.6%. Conclusion The veno-arteriolization of bilateral proper digital artery amplifies the effects of veno-arteriolization of single proper digital artery, non-traumaficly and rapidly disables valves, increases effective perfusion, significantly increases the survival of replanted fingers, promotes the growth of nail and recovery of sensadon, increases the motion of digital joints, and provides a more effective remedial method for repairing severed fingers after normal methods have failed.