单手多块复合组织离断再植疗效分析

Efficacy analysis of replantation of multiple composite tissues in single hand

目的探讨采用显微外科吻合技术进行单手多块复合组织离断再植的临床疗效。方法回顾性分析2008年5月至2021年12月, 上海健康医学院附属崇明医院和温州医科大学附属台州医院收治的单手多块复合组织离断再植患者的临床资料。术前评估手部组织块离断的部位、解剖层次、损伤原因、损伤程度、离断组织面积、再植条件(如可供吻合的血管), 据此进行改良分型(分为Ⅰ~Ⅳ型), 并设计手术方案。急诊对离断复合组织块进行清创后, 固定离断的骨性和肌性组织, 在高倍显微镜下采用显微外科技术吻合动、静脉和神经, 动、静脉的比例为1∶1~1∶2, 如无法找到足够的动、静脉, 可以采取动静脉短路形成动脉静脉化皮瓣或静脉动脉化皮瓣, 或者只吻合动脉形成动脉皮瓣, 或者只吻合静脉形成静脉皮瓣, 通血后缝合皮肤组织。术后给予患者专科治疗, 并指导其康复锻炼。术后对手部伤口愈合情况、皮肤色泽、质地、肿胀程度、感觉、关节疼痛程度、活动功能进行随访;末次随访时由患者对治疗效果进行自我评价, 分为满意、一般、不满意3个等级;由1位主任医师和1位主治医师依据中华医学会手外科学会上肢部分功能评定试用标准对手部功能和外形进行综合评价, 80~100分为优, 60~79分为良, 40~59分为可, <40分为差。结果共纳入35例患者94块离断组织, 其中男20例, 女15例;年龄16~65岁, 平均36.4岁;Ⅰ型组织块18例(50块), Ⅱ型组织块15例(40块), Ⅲ型组织块2例(4块)。35例中有1例拇指指腹离断组织因局部挫伤致术后边缘(0.3 cm×0.5 cm)坏死, 1例示指中、末节侧方离断组织因局部撕脱伤致术后边缘(0.3 cm×0.8 cm)坏死, 均经换药后创面愈合, 其余患者手部复合组织离断再植全部成活。术后随访3~65个月, 平均18.5个月, 手部伤口完全愈合, 再植组织块皮肤色泽、弹性、质地与周围正常皮肤接近, 手部无明显肿胀、萎缩畸形, 感觉功能恢复均为S2~S3级, 瘢痕较小, 活动自如, 无明显关节疼痛。患者自我评价:满意31例, 一般4例;手部功能和外形综合评价:优23例, 良9例, 可3例, 优良率约为91.4%(32/35)。结论单手多块复合组织离断再植虽然手术操作难度较大, 血管吻合技术要求高, 但手术一旦成功, 手部功能和外形均能得到良好的恢复, 患者满意度亦较高。

ObjectiveTo investigate clinical curative effect of multiple composite tissues replantation with microsurgical technique in single hand.MethodsFrom May 2008 to December 2021,the clinical data of patients who underwent multiple composite tissue replantation in single hand in Chongming Hospital Affiliated to Shanghai University of Medicine&Health Sciences and Taizhou Hospital of Zhejiang Province,Wenzhou Medical University,were retrospectively analyzed.According to the severed site,anatomical level,the injury cause,the severity of injury,the size of severed tissue,and replantation conditions(such as blood vessels for anastomosis),the severed tissue was evaluated and carried out modified classification(typeⅠ-Ⅳ)before the operation,and the surgical plan was designed.The severed composite tissue was debrided in emergency,the severed bone and muscle tissue were fixed,and the arteries,veins and nerves were anastomosed by microsurgical technique under a high-power microscope.The ratio of arteries to veins was 1∶1-1∶2.If enough arteries and veins could not be found,arteriovenous shunt could be used to form arterial venous flap or venous arterialized flap,or form artery flap by just artery anastomosis,or form venous flap by just vein anastomosis.Then skin tissue was sutured after recanalization.After the operation,the patients received specialized treatment and guided rehabilitation exercise.The wound healing of hand,skin color,skin quality,swelling degree,sensation,pain degree of joint,and activity function were followed up after the operation.At the last follow-up,the patient’s self-evaluation of the treatment effect was divided into three levels:satisfactory,average,and unsatisfactory.One chief physician and one doctor-in-charge were responsible for the comprehensive evaluation of curative effect,according to the assessment standard for upper limb function issued by Chinese Medical Association of Hand Surgery.80-100 points were excellent,60-79 points were good,40-59 points were fair,and<40 points were poor.ResultsA total of 94 severed composite tissues in 35 patients,including of 20 male patients and 15 female patients were enrolled.The average age was 36.4 years(range,16-65 years).Fifty severed tissues in 18 cases were classified into typeⅠ,40 severed tissues in 15 cases typeⅡ,4 severed tissues in 2 cases typeⅢ.Among the 35 cases,1 case of thumb pulp severed tissue was necrotic at the edge(0.3 cm×0.5 cm)due to local contusion,1 case of index finger lateral severed tissue was necrotic at the edge(0.3 cm×0.8 cm)due to local avulsion injury,and healed after dressing change,and the other replanted composite tissue survived.The patients were followed up for 3 to 65 months(average,18.5 months).The wounds were completely healed,and the color,elasticity,and quality of the replanted tissue was close to the surrounding normal skin.There was no obvious swelling or atrophy deformity of the hands.According to the patients’self-assessment,31 cases were satisfied and 4 cases were average.Comprehensive evaluation of hand function and appearance:excellent in 23 cases,good in 9 cases,fair in 3 cases,excellent and good rate was about 91.4%(32/35).ConclusionThough multiple composite tissues replantation with microsurgical technique in single hand is difficult,and vascular anastomosis technical requirement is high,once surgery succeeds,the function and appearance can get good recovery,and patient satisfaction is also relatively high.