严重肢体损伤保肢与截肢的治疗选择

Options of limb salvage or amputation in severe limb injuries

目的通过回顾性总结我科5年来所治疗的严重肢体损伤病例,探讨严重肢体损伤保肢与截肢的治疗选择。方法以毁损肢体严重性（mangled extremity severity score,MESS）评分系统为基础,综合患者全身状况、肢体功能预估、患者及家属意愿等因素,对严重肢体损伤166例（169肢）分成三组进行保肢与截肢的回顾性分析,A组：MESS评分〉9分64例（65肢）果断截肢。B组：MESS评分〈7分的41例（41肢）保肢。C组：7-9分的61例（63肢）,其中59例（61肢）试行保肢。保肢手术多经历I期急诊血运重建手术、II期骨及皮肤软组织功能重建手术,最长治疗时间2年6个月,最多经历手术8次。结果 A组64例（65肢）全部选择截肢。B组选择保肢41例（41肢）,3例（3肢）延迟性截肢,保肢成功38例（38肢）,保肢成功率为92.6%,C组选择保肢59例（61肢）,1例因术后出现多器官功能衰竭死亡,17例延迟性截肢,保肢成功43肢,保肢成功率为68.3%。B,C组共79例（81肢）保肢成功,77例患者满意,2例效果差。结论显微外科技术是保肢的技术保证;保肢与截肢的选择,首先要遵循生命第一、肢体第二的原则;其次,MESS评分系统是目前比较客观、有效判断是否保肢的标准,要以此为基础再综合其它因素进行选择;7-9分的严重创伤肢体可试行保肢治疗。

Objective To investigate options （ limb salvage or amputation ） in the treatment of severe limb injury by analyzing patients collected within 5 years retrospectively. Methods Based on MESS scoring system, general condition, limb function prediction and will of patients and their families were collected to conduct analysis. One hundred and sixty-six patients （ 169 limbs ） were divided into 3 groups. Group A （ 64 patients, 65 limbs ）： MESS score〉9. Group B （ 41 patients, 41 limbs ）： MESS score 〈7, had limb salvage. Group C （ 61 patients, 63 limbs ）： ≤MESS score 7-9, had limb salvage trail. Most of the limb salvage surgeries underwent I emergency revascularization surgery and II reconstruction surgery of bone, skin and soft tissues. Duration of treatment： the longest 30 months. Operation time： 8 times at most. Results Group A： all patients （ 64 patients, 65 limbs ） were conducted amputation. Group B：limb salvage in 41 patients, delayed amputation in 3 patients, salvage succeeded in 38 patients, success rate 92.6%. Group C： limb salvage in 59 patients （ 61 limbs ） , multiple organ failure and death in 1 patient, delayed amputation in 17 patients, salvage succeeded in 43 limbs, success rate 68.3%. Group B＋Group C： salvage succeeded in 79 patients （ 81 limbs ）, satisfactory results were achieved in 77 patients, 2 patients with poor effects. Conclusions Microsurgery technique guarantees limb salvage. The principle of limb salvage or amputation： life comes first, limbs come second. MESS scoring system is a basic, objective, and effective judgment standard of limb salvage, while other factors should also be taken into account. Severely injured patients of MESS score 7-9 may be conducted limb salvage.