断指再植术后静脉危象的外科治疗方法的对比研究

发布时间：2018-04-08 22:32

  本文选题：再植术　切入点：静脉危象　出处：《河北医科大学》2015年硕士论文

【摘要】：目的:在临床中,断指再植术后出现血管危象,尤其是静脉危象时,治疗较为困难,再植指坏死率较高。本研究旨在选择两种临床疗效较为确切的外科静脉皮瓣进行手术治疗,解决再植术后静脉危象问题,并对所述两种手术方法进行临床对照分析,以期选择出符合临床规范的手术方式,应用于临床。方法:自2013年7月至2014年12月,选定河北省沧州中西医结合医院收治的手指离断伤患者,均为单指离断伤,经再植术后出现静脉危象者,28例患者28指断指作为研究对象。本组患者再植术后2~72 h出现静脉危象经保守治疗无效,选择损伤平面位于远指间关节至指蹼水平者纳入组内,行知情同意告知后,随机分为两组,每组14指。两组28例患指均由同一组经专业培训的术者及助手实施手术,第一组带蒂邻指静脉皮瓣组于术中切除再植指指背炎性水肿皮缘及栓塞静脉段后,切取相邻手指背侧包含至少2条静脉的带蒂皮瓣转位至再植指指背区,该皮瓣长度约4.0~4.5cm,宽度约1.2~1.5cm。将相邻手指皮瓣静脉与再植指指背静脉吻合,供区植全厚皮片,加压打包。术后抗炎抗凝抗痉挛治疗,断指成活后,邻指皮瓣四周断蒂,行功能锻炼。第二组游离静脉皮瓣组于前臂屈侧或手(指)背选择有两条并行静脉的部位进行切取,两条静脉需包含在游离静脉皮瓣的纵轴上且平行分布,皮瓣大小为1.5*1.2~1.5*2.0cm,在10倍显微镜下将游离静脉皮瓣嵌入缺损部位,皮瓣不倒置。其中一条静脉干与再植指指背远近端的静脉端端吻合,另一条静脉干近端结扎,远端与非优势侧或未吻合的指动脉远断端端端吻合。供区直接缝合,无需断蒂。于术中记录两组手术方式各自所用时间(包括患指的清创,皮瓣的切取,供区的处理以及血管吻合);术后观察患指血运情况,两组转移或移植创面皮瓣的颜色,饱满度等指标。两组指体的外观分析评价方法按照中华医学会手外科学会上肢部分功能评定试用标准评定和密歇根手调查问卷(MHQS)评定表对两组进行对照分析。计量资料均采用均数±标准差表示,两组间比较采用单因素方差分析,方差不齐时应用对方差进行校正的Welch方法,所有数据用SPSS 19.0软件统计处理,检验水准α=0.05。结果:1两组手术时间对照分析:带蒂邻指静脉皮瓣组手术时间为64±4.80分钟;游离移植静脉皮瓣组手术时间平均82±3.60分钟。两组手术时间比较,P0.05,两组有显著性差异。2成活情况对照分析:带蒂邻指静脉皮瓣组完全成活11例,痂下愈合2例(多因浅表皮肤水泡破溃形成),部分坏死1例;游离移植静脉皮瓣组完全成活7例,痂下愈合5例,部分坏死2例。部分坏死病例均经植皮或局部皮瓣转移修复后成活。两组手术成功率比较,P0.05,两组有显著性差异。3临床疗效的术后比较:术后随访2~12个月,平均6.7个月,所有病例均接受随访,无脱落病例。根据中华医学会手外科学会上肢部分功能评定试用标准评定和密歇根手调查问卷(MHQS)评定表,带蒂邻指静脉皮瓣组术后感觉测定,优10例,良3例,中1例;活动度测定(TAM)优11例,良3例;无触痛13例,有触痛1例;供区愈合情况,优12例,良2例。游离移植静脉皮瓣组感觉测定,优7例,良5例,中2例;活动度测定(TAM)优10例,良4例;无触痛11例,有触痛3例;供区愈合情况,优12例,良2例。两组手术临床疗效比较,P0.05,两组差别有统计学意义。结论:1带蒂邻指静脉皮瓣的外科方法不仅用健康的皮肤覆盖了缺损部位,与此同时也修复了再植指的静脉回流,相对来说,手术较实用,安全和简便,但是需二次断蒂,对相邻手指有轻度功能及美观影响。2游离移植静脉皮瓣的临床应用效果较好,供区可直接闭合,但对显微外科技术要求较高,且因血供为非生理性动脉血供,故皮瓣坏死率高,术后皮瓣有不同程度的回缩,成活质量较差,故游离静脉皮瓣可在特殊病例中选用。3临床上单指再植术后发生的静脉危象,外科皮瓣选择带蒂邻指静脉皮瓣疗效更佳。
[Abstract]:Objective: in clinical practice, vascular crisis occurred after finger replantation, especially venous crisis, treatment is difficult, the necrosis rate of replantation surgery is high. The purpose of this study is to select the venous flap two clinical curative effect accurate surgical treatment, venous crisis after replantation of problem solving, and two kinds of operation method of the a comparative clinical study was carried out, in order to choose the mode of operation in accordance with the clinical criterion, for clinical application. Methods: from July 2013 to December 2014, combined with the selected hospital finger amputation patients in Hebei of Cangzhou Province Traditional Chinese medicine and Western medicine were single finger amputation, after replantation venous crisis occurred in 28 cases, 28 finger as the research object. This group of patients after replantation of 2~72 h venous crisis occurred after conservative treatment is invalid, injury plane located at distal interphalangeal joint to finger web level into groups, informed consent xingzhi, Were randomly divided into two groups, each group of 14. Two groups of 28 patients were referred to by the same group by professional training technique and the assistant operation, the first group of pedicled finger vein flap group in resection of replantation of finger dorsum skin edge and inflammatory edema embolism vein, cut dorsal adjacent contains at least 2 finger vein pedicle flap transposition to replantation of finger dorsum flap, the length of about 4.0~4.5cm, width of 1.2~1.5cm. the adjacent finger vein and dorsal flap replantation of finger vein anastomosis, donor graft full-thickness skin graft, compression packing. Postoperative anticoagulation anti-inflammatory antispasmodic, finger, finger around the pedicle flap, functional exercise. Second groups of free vein flap group in the forearm or hand (finger) choice back there are two parallel vein parts were cut, two veins will be included in the longitudinal free vein flap on flap and parallel distribution, the size of 1.5*1.2~ in 1.5*2.0cm. 10 times under the microscope of free vein flap embedded defect. The flap is not inverted. One vein and replantation of finger dorsum of proximal and distal venous anastomosis, another vein distal and proximal ligation, non dominant side or anastomosis of finger artery distal end end anastomosis. The donor site was closed directly. Without pedicle. In operation records of two groups of operation each time (including finger debridement, flap, donor and vascular anastomosis); postoperative finger blood supply, two groups of transfer or transplantation of skin flap color, plumpness index two. The appearance of the group refers to the analysis and evaluation methods in accordance with the hand surgery society of Chinese Medical Association the upper extremity functional evaluation standard and Michigan Hand questionnaire (MHQS) scale were compared in two groups. The measurement data are expressed by the mean and standard deviation, the two groups were compared using single Factor analysis of variance, homogeneity of variance using variance Welch correction method, all data using SPSS statistical processing software 19, a =0.05. level test results: 1 the operation time of the two groups were analyzed: pedicled finger vein flap group operation time was 64 + 4.80 minutes; free flap vein graft operation time was 82 + 3.60 minutes. Compared the operation time of the two groups of P0.05, there was significant difference between two groups.2 survival analysis: control of pedicled finger vein flap group 11 cases survived completely, 2 cases of crust healing (due to superficial skin blisters rupture formation), partial necrosis in 1 cases; graft venous flap group 7 cases completely survived, wound healing in 5 cases, 2 cases of partial necrosis. Partial necrosis were treated by skin graft or flap survived after two. The success rate of operation was compared, P0.05, two groups have significant clinical curative effect difference of postoperative.3 is: 2~12 months follow-up ,骞冲潎6.7涓�鏈�,鎵，

本文编号：1723671