Replantation of amputated limb (finger)

Since Chen Zhongwei et al. (1963) first replanted a patient with a complete forearm in China, the replantation of the limb (referred to) has been carried out nationwide, and gratifying progress has been made. With the increase of clinical practice, especially since the 1970s, the application of microsurgery technology to the replantation of severed fingers, the survival rate of finger replantation increased from 63.7% to 93.2%, and even the ten fingers completely replanted and survived. Reported, and replanted limbs and fingers have a certain functional recovery. However, replantation of the broken limb (referring to) is a new topic in trauma surgery, and there are still some problems that need to be resolved. Treatment of diseases: replantation of severed fingers Indication The broken limb (referring to) is caused by trauma, but the cause of the injury and the severity of the injury are different. The systemic and local pathological changes of the patient with the broken limb are also different. Therefore, the indications for replantation surgery are not absolute, but relative. The general requirement is to ensure that the wounded are safe and do their best to retain any useful limb or finger for the patient and decide to amputate. Whether to replant, the following issues should be considered: 1. The general condition of the whole body is good, and those who can tolerate replantation should consider replanting. Generally speaking, the violence that causes the broken limbs is often very large. Except for the limbs, it is easy to have shock and major organ damage. When the casualty is accompanied by shock and important organ damage, it should be urgently treated to save lives. The broken limb (referred to) can be temporarily refrigerated and stored. When the injured person's general condition improves, he can tolerate the operation and then replant. Conversely, if the patient's shock lasts for a long time, or if the organ damage is unstable after treatment, the replantation should be considered. 2. Local condition The purpose of replantation of the limb (referred to) is not to replant, but to restore function. This requires that the limbs or fingers that are to be disconnected should have a certain length and integrity, especially for important tissues that constitute limb function, such as bones, blood vessels, nerves and muscles, to be carefully examined and judged. (1) Length of bone defect: The bone is a support for various functional tissues of the limb, and it is required to have a certain length, and the bone cannot be shortened without limitation. In general, the main function of the upper limbs is the movement of the fingers. Even if the bones are shortened more, they may still have certain functions, which are more flexible and practical than the prostheses. The function of the lower limbs is mainly weight-bearing and walking. If the bone shortens more than 15-20 cm, it can not adapt to walking and lose the meaning of replanting. Both sides of the lower limbs are disconnected, and the relative is not limited by the shortening of the bone. Simultaneous replantation or replantation on both sides can adjust the length of each other, such as replantation of one limb, and the other side can be compensated by the same length of prosthesis. The hand is a delicately active organ, which is the exposed part of the human body. The shortening of the phalanx is more than 2.0cm, which not only affects the function, but also is not beautiful. (2) The degree of vascular injury: Where the intima of the blood vessel is extensively damaged, it is estimated that it is difficult to solve with vascular grafting, or the distal small blood vessels and capillaries are extensively damaged due to crushing injury, or the distal blood vessel is caused by a crushing injury of the gear. Extensive segmental injury [Figure 9], or due to avulsion injury, the branches of the main artery are extensively torn; or the broken limb (finger) is directly immersed in hypotonic, hypertonic or coagulating disinfectant, resulting in endovascular Those who are injured should not be replanted. (3) Degree of nerve damage: If the nerve damage is serious and cannot be repaired or reconstructed, even if it is replanted, the limb has no function, but becomes cumbersome. High limbs of the upper extremities, brachial plexus extracted from the intervertebral foramen, there is no effective treatment, and should not be replanted. (4) The degree of muscle damage: Muscle is the driving force of limb activity. Only with certain sound nerves and muscles can the basic function of the limb be satisfied. Therefore, a wide range of muscle crush injury and inactivation, or violence, the muscles or muscle fibers longitudinally split, and the blood vessels between the muscle bundles, such as the removal of these muscles, will inevitably affect the body function, and can not be transferred later with tendon , or anastomosis of blood vessels, nerves, muscle transplant reconstruction function, should not be replanted. 3. The time limit of replanting is well known. For example, the ischemic time of the broken limb is too long. Due to hypoxia and other reasons, the cells are degenerated, necrotic, and finally form irreversible degeneration. At this time, even if the blood vessel is turned on and the blood flow is restored, the broken limb (referring to the limb) is not able to survive, but may cause poisoning or even death due to absorption of a large amount of metabolites and toxins. Therefore, the time when the blood loss of the broken limb (referred to) is interrupted to replantable is not unlimited, but has a certain limit. This limit is called the replantation time limit. The replantation time limit is not absolute, but relative. It is related to the level of the limb's plane of separation, the amount of muscle contained in the limb, and whether it has been cryopreserved. In general, the higher the plane of the limb, the more muscle it contains and the shorter the time to withstand ischemia. Low temperature can reduce cell metabolism, reduce energy consumption, and prolong the time to tolerate ischemia. So far, the clinically broken limbs have been successfully replanted for 36 hours. The animal experiment has removed the dog leg and refrigerated at 0 to 4 °C for 108 hours. It is still replanted successfully and resumes function. However, Shanghai Sixth People's Hospital reported (1972) 114 cases of various types of limbs, the survival rate of 47 cases within 5 hours of replantation was 95.7%, 37 cases within 10 hours, the survival rate was 78.4%, 10 hours. In the above 30 cases, the survival rate is 60%. Therefore, the replantation of the broken limb (referred to) should have a certain time limit, and it may be different due to various factors. It should be analyzed according to the specific situation and judged. 4. Characteristics of broken fingers Clinically, broken fingers are more common than broken limbs. In addition to the above points, the indications for replantation of severed fingers should also be considered: (1) The anatomical features of the fingers are skin, bones, small nerves, only tendons, no muscles, and the strongest tolerance to ischemia and hypoxia. Therefore, the replantation time limit can be longer than the fractured limb. (2) After the finger is disconnected, there is not much bleeding, the whole body is less disturbed, it is not easy to cause serious complications such as shock, and it rarely causes serious poisoning and other changes; and with the development of microsurgical technology, the survival rate of finger replanting reaches 93.2. %. Therefore, some people advocate that the main functional fingers under the age of 50 (thumbs or four fingers at the same time), and the proximal side of the distal interphalangeal joints should be replanted or displaced. A single finger disconnection should be based on the patient's condition, the integrity of the finger, and it is estimated that the finger function can be restored after replanting. (3) The function of the thumb, the indicator and the middle finger is important. Whether it is multiple finger or single finger, if necessary, it should be replanted or displaced. (4) The distal interphalangeal joint is distally broken. Because the blood vessel is small, it can be sutured directly or sutured. Preoperative preparation 1. Infusion, blood transfusion to correct blood volume deficiency, stabilize the general condition. 2. Before replanting, the broken limb (finger) should be stored in cold (0 ~ 4 ° C). 3. X-ray films should be taken in the proximal and distal segments of the broken limb (finger) to understand the fracture or dislocation. 4. Patients with broken limbs (referring to) should be tested according to the injury, such as blood, urine routine, ion measurement, CO2 binding capacity and urea nitrogen. 5. Check the blood type and match the blood. 6. High limbs, severe systemic conditions, should be placed in the catheter, remember the amount of urine per hour. 7. Tetanus antitoxin 1500 units intramuscular injection. 8. Antibiotic prophylactic application: generally use 1 million units of penicillin and 80,000 units of Qingda toxin, intravenously, once every 6 hours. Prophylactic antibiotic prophylaxis is best started within 3 hours of injury and lasts 1 to 3 days. Surgical procedure The surgical procedure for replantation of a broken limb is as follows: Debridement debridement is the basis for successful replantation of severed limbs. Detailed and thorough debridement is an important measure to ensure that wounds are not infected, blood vessels are sutured smoothly, nerve function is restored and poisoning is reduced. The principle of debridement is to remove all foreign bodies and contaminated and inactivated organizations. For organizations suspected of being inactivated, they may be temporarily retained. It is decided to remove them after the second debridement after the recovery of blood supply. Never leave the inactivated tissue barely to take care of the length of the limb or blood vessel. In order to shorten the operation time, the complete limbs are often divided into two groups, respectively, to treat the proximal and distal segments of the limb (finger), and to identify the main blood vessels, nerves, muscles and tendons at the same time as debridement. (1) General debridement: wash and disinfect the surrounding skin, see debridement. (2) Debridement of skin, tendons, muscles and bones, where the skin is dark purple, intradermal hemorrhage, or thinning of the skin, or extensive separation from the subcutaneous tissue, indicating that the skin has lost vitality and should be removed. If the superficial superficial vein is not damaged, it should be retained for anastomosis. Where the muscle fiber is longitudinally separated, there is a hematoma in the muscle, the muscle fiber lacks elasticity, the clip is fragile, or the muscle does not bleed when cutting, or the muscle is not contracted, etc., should be regarded as inactivated and should be removed. Because the muscles and skin of the distal segment of the complete limb (finger) lose blood supply and innervation, it is difficult to identify whether it is inactivated, and should be identified after re-invasion after restoring blood flow. Tendons are determined by the color (normal white tendon is white and shiny), the tendon stump, and the integrity of the diaphragm. For functionally repeating tendons, the resectable function is secondary, while retaining the function of the main tendon. If the flexor digitorum, superficial tendon should be removed from the superficial tendon, the deep muscle tendon should be retained to reduce adhesion. Remove a few bone ends to remove contamination. The broken bone pieces connected to the soft tissue should be preserved after washing with physiological saline and dip for 1:1000 benzalkonium for 5 minutes. (3) debridement of blood vessels: first find the main blood vessels. Generally speaking, the blood vessels of the broken limb are relatively large, and it is easier to find out according to the anatomical position. The broken blood vessels are small and should be looked under the microscope. The finger artery is located on both sides of the flexor tendon sheath, the dorsal aspect of the nerve and the deep ligament of the bone, the proximal end of the broken finger can be found according to the arterial pulsation, and the distal end needs to longitudinally cut the skin and the ligament of the bone. 0.5cm, and flipped backwards, can be found. Anatomically, the superficial vein is located under the skin of the finger, and the back of the finger is visible on the dorsal side of the proximal segment of the finger. In the distal segment, because there is no blood supply, the back vein is not filled, and it is difficult to find. The methods to be searched include: 1 A small red dot can be seen under the skin of the dorsal side of the distal section, that is, the opening of the superficial vein of the finger is broken; 2 the finger is folded, and the direction of the superficial vein of the proximal finger is sought. The distal finger is the dorsal vein; 3 is slowly injected from the distal finger artery with heparin saline (12.5 u/ml), and the distal section has a fluid outflow, ie, a venous opening. If the above method is used, the finger vein can still not be found. In the proximal and distal segments of the finger, each can make a Z-shaped incision at an angle of 60°, and the triangular flap can be turned over to the base, which is extremely easy under the microscope. Find the finger vein. Be careful not to damage the subdermal vein during the flapping process. Followed by the perfusion of the broken limb (finger), the purpose is to understand the complete condition of the vascular bed of the broken limb (finger), rush out of metabolites and small clots to reduce poisoning and thrombosis. In general, the broken finger is inserted into the finger artery with a 5th flat needle, and 10 to 20 ml of the heparin saline solution is slowly injected. The broken limb was inserted into the main artery with a flat needle of 12 to 18, and the artery and the needle were pinched by hand, and the heparin salt aqueous solution was slowly injected. If there is no resistance in the injection, the broken limb (refers to) is not swollen, the irrigation fluid branches from the upper artery of the section, the vein breaks and the marrow cavity flows out, and the vascular bed of the broken limb (finger) is complete and can be replanted. The amount of the rinsing liquid to be injected is adjusted to the degree of the reflux liquid. Conversely, if the resistance is large, the diffuse swelling or limited swelling of the broken limb (finger), the venous and medullary cavity of the cross section does not return much, or the irrigation fluid flows out from the intermuscular space or the muscle fiber, indicating the vascular bed of the broken limb (finger) Blocking or rupturing, replanting may fail. Attention should be paid during perfusion: the flat needle should be inserted from the branch of the artery. If it is inserted into the main artery, the operation should be gentle and correct to avoid damage to the endometrium. Inject the irrigation solution slowly, not too fast, so as not to overstress and damage the intima. After understanding the integrity of the vascular bed of the broken limb, the injured blood vessel is observed under the operating microscope. The blood vessel wall is dark red, the blood vessel wall is hematoma, the endometrium is ruptured, or the large blood vessel is avulsed from the proximal end. Thrombosis should be removed. Debridement of blood vessels must be thorough, retaining any damaged blood vessels, which will inevitably lead to thrombosis, leading to failure of replantation. (4) Debridement of the nerve: When there is no obvious contusion at the nerve ending, under the suture traction, the contaminated part of the nerve ending is removed with a blade and observed under a microscope. If the nerve bundle is protruding, the tunica is intact, and there is no hematoma between the bundles. It is a normal nerve bundle that can be sutured. If the nerve contusion is extensive and serious, or for the avulsion injury, a large segment of the nerve is pulled from the proximal end. If it is difficult to determine the extent of the injury, after clearing the obvious contaminated part, the nerve ends are pulled together and fixed with black lines to the nearby soft tissue. On, wait for the second phase of processing. 2. Reconstruction of the bone scaffold The reconstruction of the bone scaffold is the basis of soft tissue repair. Only after the fracture has a strong internal fixation, after the stability of the bone scaffold is restored, the repair of blood vessels, nerves and other tissues is possible. Before reconstruction, the need for debridement of contaminated bone ends should be considered, as well as the shortening of soft tissue after debridement, especially the need for blood vessels and nerves to repair under tension without shortening the bones. In general, even if the bones of the upper limbs are shortened more, the function is better than the prosthesis. However, if the bones of the lower limbs are shortened by more than 15 cm, it is difficult to adapt to the needs of weight and walking. When the phalanx is shortened by more than 2 cm, it can affect the function and appearance. Once the bone is shortened, it can be fixed internally. The principle of internal fixation is simple, reliable, and minimizes damage, preferably without joints. Generally, the broken finger and the broken palm can be fixed by Kirschner wire. The broken limb that has been broken by the backbone can be sawed into an L-shaped or large inclined surface when the bone is shortened, and fixed with two screws, or fixed with a steel plate and a screw or an intramedullary nail. After the dry limb is broken, the end of the bone can be inserted into the medullary cavity of the metaphysis, and then fixed with 1 or 2 screws. Arthroplasty can be considered for the broken limb (finger) that has been broken by the joint, such as the joint surface has been destroyed. 3. Reconstruction of vascular blood vessels is the key to restoring the blood circulation of the broken limbs. It not only determines the success or failure of the replanted limbs, but also affects the function of the broken limbs. Reconstruction of the blood circulation of the broken limb means that there is sufficient flow of arterial blood to perfuse the tissue, and there is also sufficient venous return to maintain a relative blood flow balance. If this relative balance is lost, even if the blood vessels are connected, it will cause ischemia or blood stasis of the broken limb. Clinical practice proves that in order to maintain the relative balance between arterial blood supply and venous return, and prevent swelling of postoperative limbs (finger), the number of arterial and venous sutures is preferably 1:1.5-2. Before suturing the blood vessels, the soft tissue around the deep and the fracture end should be sutured as necessary to protect the fracture end, eliminate the dead space, reduce the tension during vascular suture and provide a good vascular bed. At the same time, under the microscope to check whether the blood vessel debridement is thorough, all the suspected damaged blood vessels should be completely removed, and can not be tolerated. Then, the outer membrane of the blood vessel is pulled to the end of the blood vessel by microscopic forceps, and the straight end is cut off with a straight cut, and if it is naturally retracted, the naked end of the blood vessel has a white exposed portion of 1 to 2 mm for suturing. At this time, the blood vessel clip or the gas tourniquet of the proximal artery can be loosened to observe the arterial blood spurting. If the arterial pulsation is not good, no jet bleeding, mostly due to proximal arterial spasm or thrombosis, should be excluded. Only after a certain ejection hemorrhage can the blood flow be blocked by the blood vessel clamp and the suture is prepared. When the blood vessel is sutured, check whether the outer diameter of the blood vessel end is close. In general, when the limb is replanted in situ, the outer diameter of the vascular end is roughly similar, and the end suture is not difficult. In some cases, when the outer diameter is inconsistent due to vasospasm or shortening of the limb, it is possible to cut the end having a small outer diameter into a slanted opening, or to expand the end having a small outer diameter by a vasodilation method. The suture method uses two fixed point stitching methods or three fixed point stitching methods. Generally, small blood vessels with an outer diameter of 2 mm or less are often sutured with 9-0 to 11-0 non-invasive needles; vessels with an outer diameter of 3 mm or more can be intermittently or continuously sutured with 7-0 to 8-0 non-invasive needles. When suturing blood vessels, you should pay attention to: (1) Vasospasm: The smaller the blood vessels, the more likely the vasospasm occurs. Once the vasospasm occurs. The blood volume should be supplemented first, and the hot saline solution can be applied locally or wetted with warm 5% papaverine, 2% procaine or 6% magnesium sulfate solution. If it is invalid, it can be expanded by hydraulic pressure, that is, it is inserted into the blood vessel with a flat needle, and heparin saline is injected, and the pressure is expanded in stages [Fig. 12]. This method has no obvious damage to the tube wall, and the effect is indeed. (2) Sequence of arterial and venous sutures: suture the arteries first or suture the veins first, each with advantages and disadvantages. In fact, with the advancement and proficiency of small vessel anastomosis technology, it takes less time to fit a blood vessel. Therefore, no matter whether the artery is sutured or the vein is sutured first, at least one artery and one vein should be sutured before the limb is restored. Refers to the blood flow, so as not to lose too much blood. The number of sutures and veins is generally 1:1.5-2. (3) refers to the suture of the dorsal vein is a difficult problem of replantation of the broken finger. Because the wall of the dorsal vein is thin, the outer membrane should not be removed too much, so as not to hurt the muscle layer, and the lumen collapses, and the tube is not clear. In addition, the dorsal vein is curled under the skin, the mouth is not easy to see, the assistant can use heparin saline to flush the nozzle. Due to the siphon effect of the capillaries, the venous orifice is opened immediately, the surgeon can enter the needle, the back vein After the suture is completed, the skin at the anastomosis should be covered with a number of stitches to prevent the vein from drying or being damaged. (4) Repair of vascular defects: After extensive debridement of blood vessels, there are many vascular defects, and the methods for overcoming vascular defects are as follows: 1) Shorten the bone: shorten the length so that the main blood vessels and nerves can be directly sutured without affecting the function of the limb or finger. 2) For vessels with an outer diameter > 2 mm, the length of the defect is < 2 cm, and in the vicinity of the joint, the free vessel and the flexion joint can be used to suture the vascular end. For vessels with an outer diameter >2 mm, the length of the defect is >2 cm, and the slightly flexed joint can not be used to directly align the vascular end. Only the autologous or autologous vein with the same outer diameter is transplanted for repair. In general, there are very few sources of autologous arteries above 2 mm, so autologous superficial vein grafts are often used for repair. 3) When a single finger is replanted, if there is an arterial defect, it may be repaired by cutting one side of the arteries, or by displacement of the adjacent finger artery. If it is a venous defect, it can be repaired by a finger vein adjacent to the finger vein of the finger, or by the displacement of the dorsal finger. When most of the severed fingers are replanted with vascular defects, they can also be solved by the above method, but the source of the grafted blood vessels is mostly taken from the uncorrected replanted finger. (5) Restoration of blood flow: When an artery and a vein are sutured, the blood vessel clamp can be removed to observe whether the blood circulation of the broken limb (finger) is reconstructed. If the artery on the far side of the anastomosis is pulsating, the distal skin color of the broken limb (finger) changes from pale to ruddy, the skin temperature rises, the vein fills, the distal section has active bleeding, and the acupuncture finger (toe) has blood on the abdomen. Outflow, indicating that the blood flow cycle reconstruction of the broken limb has been successful. After suturing one vein, the bleeding point of the section was ligated and the bleeding was completely stopped. 4. After rebuilding the muscles and tendons to restore blood flow, the muscles and skin suspected to be inactivated should be re-examined for the first debridement. If it has been inactivated, it should be removed. Before the muscle is sutured, the corresponding muscles and tendons on both sections should be identified. The extensor tendon of the severed finger should be sutured in one stage and should be sutured before the finger vein is sutured. The proximal section should suture the central and lateral bundles of the extensor tendon, and the middle section should suture the central and lateral bundles of the extensor tendon, such as the central defect, and the lateral bundle can be sutured [Fig. 15]. The flexor tendon of the broken finger can be repaired in one stage if it is a cutting injury; if the injury is serious, the tendon defect after debridement should not be sutured in one stage, and the second stage of free tendon transplantation should be performed. The lower third of the wrist or forearm is disconnected, the volar side repairs the flexor hallucis longus tendon, the distal deep flexor tendon is sutured with the proximal flexor tendon, the dorsal lateral repair of the longus tendon, the temporal wrist length, the short extensor tendon and extension Refers to the total tendon, and the remaining tendons can be retracted after being removed under traction. Stitching method: The muscles are sutured from deep to shallow with suture, and each needle is sewn as much as possible and part of the tendon to eliminate the dead space. The suture of the tendon can be performed by Bunnell suture or double cross suture. After the suture is ligated, if the tendon is not tightly closed, the suture can be intermittently added with 1 to 2 needles. Fish tendon sutures can be used for tendons with large differences in thickness. For the fracture of the tendon and the abdominal joint, the tendon should be sutured 1 to 2 needles, fixed in the muscle abdomen, and then the muscle abdomen is wrapped around the tendon, and several needles are intermittently sutured. The first-stage suture of the flexor tendon can be performed with two straight needles of 2-0 to 3-0 nylon thread, and should be sutured before suturing the blood vessels and nerves. When repairing tendons, care should be taken not to suture as much as possible in the same plane. The ends of the tendon sheath should also be sutured as much as possible to protect the tendon from reduction and adhesion. 5. Repairing the nerve In principle, the broken nerve should be repaired in one stage, which is not only conducive to the reconstruction of the function of the broken limb (finger), but also the anatomical landmark of the nerve section is clear, the operation is convenient, and the effect is better. If the nerve is defective, nerve transposition or shortening the bone is easier than the second stage surgery. Therefore, only when the nerve is severe and extensively contused, it is difficult to judge the extent of resection, and the second-stage suture is performed. For the nerves that determine the second stage of repair, the black line can be used to draw the broken end and fixed on the nearby muscles, so that it is easy to find in the second stage operation. Whether it is an epicardial suture or a bundle suture, the nerve suture should be performed under a surgical microscope. Only under the microscope can the broken ends of the nerve bundles be satisfactorily aligned. If the nerve defect exceeds 2cm, the inter-beam nerve bundle transplantation should be performed. When the finger is replanted, the finger nerve should be sutured in one stage, so as to restore the feeling of finger breaking as soon as possible. When conditions permit, the two finger nerves should be sutured at the same time. If unconditional, the indications, middle and ring fingers should be repaired as much as possible, while the thumb and the little finger should be repaired. If the nerve is defective, the ipsilateral side can not be directly sutured, and nerve bundle transplantation or nerve cross suture can be used, that is, the partial nerve bundle of the adjacent finger is displaced with the distal finger nerve of the broken finger [Fig. 17]. 6. Closing the wound surface, if the skin is sufficient, can be directly sutured to eliminate the wound and prevent infection. If there is a skin defect, the wound that remains after suturing directly can be covered with a medium-thickness skin graft. If the residual wound is a bare tendon, bone or blood vessel, or an anastomosis of the nerve, it needs to be covered with a musculocutaneous flap, a tendon flap or a local metastatic flap. When closing the wound, you should pay attention to: (1) avoid suturing the broken limb (finger) for 1 week to prevent the scar contracture and affect the reflux; (2) When the back skin is sutured, do not sew the dorsal vein of the finger, and the suture should be loose to avoid compression. The dorsal vein; (3) After the suture of the broken limb wound, the rubber tube should be placed in the interstitial space for negative pressure drainage after operation.

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