保肢治疗创伤性腘血管损伤

Limb salvage for traumatic popliteal vascular injury

目的探讨保肢治疗创伤性腘血管损伤的疗效。方法对83例腘血管损伤患者采用保肢治疗。直接吻合修复腘血管35例(直接吻合腘动脉9例,直接吻合腘静脉4例,直接吻合腘动脉及静脉22例);大隐静脉桥接修复腘血管48例(桥接腘动脉13例,桥接腘静脉2例,直接吻合腘动脉+桥接腘静脉13例,桥接腘动脉+直接吻合腘静脉10例,桥接腘静脉及动脉10例),移植长度3~30(6.8±4.2)cm。结果住院时间10~244(62.4±16.3)d。82例保肢成功,保肢率98.8%;1例行一期截肢术。术后未发生死亡、严重肝肾功能损伤。术后数字减影血管造影或B超检查腘血管修复均全部血流通畅。1例单纯腘动脉损伤患者术后10 d切口无感染,出院时未拆除缝线。其余82例一期创面愈合59例;二期创面愈合17例(扩创缝合后愈合4例,扩创皮片移植3例,扩创后股前外侧皮瓣带蒂转移修复2例,游离股前外侧皮瓣修复8例);三期及以上创面愈合6例。住院期间除1例截肢者未保留膝关节外,其余82例膝关节均恢复部分主、被动屈伸功能。出院时,踝关节及跖趾关节跖屈功能恢复62例,背伸功能恢复20例;趾感觉恢复至S2级别以上81例,恢复至S1级别1例。结论对腘血管损伤早期及时准确诊断,开通绿色通道,急诊一期直接修复血管或采用游离健侧小腿大隐静脉桥接血管,预防性筋膜室切开及坏死肌肉清除,可在较短时间内有效重建肢体血供,恢复肢体功能,同时也可避免肝肾功能损伤。

Objective To investigate the effect of limb salvage in the treatment of traumatic popliteal vascular injury.Methods The 83 patients with popliteal vascular injuries were treated with limb salvage.The 35 cases with popliteal vessels injuries were anastomosed directly(9 cases with popliteal arteries injuries,4 cases with popliteal veins injuries,22 cases with popliteal arteries and veins injuries).Great saphenous vein bridging repair was used in 48 cases of popliteal vascular injuries(bridging repair popliteal arteris injuries in 13 cases,bridging repair popliteal veins in 2 cases,directly anastomosing popliteal arteris and bridging popliteal veins in 13 cases,bridging popliteal arteris and directly anastomosing popliteal veins in 10 cases,bridging popliteal veins and arteries in 10 cases).The length of grafted vessels ranged from 3 cm to 30 cm,with an average of(6.8±4.2)cm.Results The hospital stay was 10~244(62.4±16.3)d.The 82 cases were successful limb salvage,and the limb salvage rate was 98.8%.One patient underwent one-stage amputation.There was no death or serious injury of liver and kidney function after operation.All popliteal vessels repair examined by digital subtraction angiography or B-ultrasound showed that they were unobstructed.One patient with simple popliteal artery injury had no incision infection at 10 d after the operation,and the sutures were not removed at discharge;for the orther 82 cases,there were 59 cases of primary wound healing,17 cases with secondary wound healing(4 cases healed after expansion suture,3 cases healed after expanded skin grafts,2 cases were repaired with pedicled anterolateral femoral flaps,and 8 cases were repaired with free anterolateral femoral flaps);three-stage and above wound surgical healing was obtained in 6 cases.During hospitalization,except that the 1 case amputee did not retain the knee joint,the knee joints of the other 82 patients had recovered some active and passive extension and flexion functions.At the discharge,the function of the ankle joint and plantar flexion function of metatarsophalangeal joint were restored in 62 cases,dorsal extension function was restored in 20 cases,toe sensation was restored to above S2 level in 81 cases,and 1 case recovered to S1 level.Conclusions It can effectively reconstruct limb blood supply and restore limb function in a short time,and simultaneously avoid liver and kidney function injury that the flowing methods are adopted,including early and accurate diagnosis of popliteal vascular injury in the early stage,opening green channel for first aid,directly repair blood vessels in the first stage of emergency or bridging anastomose blood vessels with free saphenous vein of healthy leg and preventive fascial compartment incision and removal of necrotic muscles.