激光多普勒血流仪在断指再植术后血运监测应用的效果研究

目的:为了提高临床断指再植手术效果,分析断指再植术后彩色多普勒血流成像仪的临床应用效果价值。方法:从2016年9月至2017年9月在我院接受断指再植术治疗的60例患者中,采用随机数表法随机将其分为实验组和对照组各30例。实验组:采用激光多普勒血流成像仪监测再植肢体血运;对照组:采用传统方法监测再植肢体血运。探讨断指再植术后彩色多普勒血流成像仪的临床应用价值。结果:研究结果显示,和对照组相比观察组患者断指再植术后血管栓塞率、血管危象发生率明显降低,而断指成活率以及成活再植指术后功能恢复情况则明显增加(P0.05)。结论:将彩色多普勒血流监测应用于断指再植术后,能够无创、实时、灵敏的反应再植指术后的血运情况,有助于及时发现各种不良事件的,提高再植成功率,效果显著,值得推广。     

Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the anatomy of the fingertip. 2. Describe the methods of evaluating fingertip injuries. 3. Discuss reconstructive options for various tip injuries. SUMMARY: The fingertip is the most commonly injured part of the hand, and therefore fingertip injuries are among the most frequent injuries that plastic surgeons are asked to treat. Although microsurgical techniques have enabled replantation of even very distal tip amputations, it is relatively uncommon that a distal tip injury will be appropriate for replantation. In the event that replantation is not pursued, options for distal tip soft-tissue reconstruction must be considered. This review presents a straightforward method for evaluating fingertip injuries and provides an algorithm for fingertip reconstruction.     

The role of angiogenesis and pulpal healing in tooth replantation and allograft transplantation

Tooth transplantation is one of the treatment options for extracted teeth that can be considered before dental implantation. Although the success rate of tooth transplantation is lower than that of implantation, tooth replantation and transplantation have the great advantage of using natural teeth. Tooth replantation might be considered a promising option in some cases. In present study, the expression patterns of revascularization and pulpal healing, which are the most important for the pulp viability, were analyzed after tooth replantation and allograft in mice. The inflammatory response and root dentin resorption were observed and not different between replantation and allograft in initiation of healing process. However, bonelike tissue formation, pulp revascularization and pulp healing were faster in replantation. The difference of healing patterns between tooth replantation and allograft found in present study will be helpful to select the treatment option and to understand healing mechanism.     

AO 微型钢板与克氏针固定在断指再植术中的临床应用比较

目的:比较AO微型钢板与克氏针内固定在断指再植术中的临床应用效果。方法:断指患者52例,其中26例(34指)断指采用AO微型钢板内固定治疗(观察组),另26例(37指)采用克氏针交叉固定治疗(对照组),术后均辅以功能康复训练。比较两组患者的手术时间、骨折愈合时间及断指功能恢复优良率。结果:观察组与对照组断指再植平均耗时分别为(83.5±10.2)min、(62.7±8.3)min(P<0.01),骨折愈合时间分别为(5.8±0.9)周、(8.4±1.7)周(P<0.01),断指功能恢复优良率分别为91.2%、62.2%(P<0.01)。结论:在断指再植术中应用AO微型钢板内固定与克氏针比较,虽手术耗时较长,但骨折愈合时间短,断指功能恢复优良,值得临床推广应用。     

Alternatives to thumb replantation

LEARNING OBJECTIVES: After studying this article, the participant should: 1. Have a variety of options for thumb reconstruction. 2. Know the advantages and disadvantages of the nonmicrosurgical and microsurgical techniques for thumb reconstruction. 3. Understand the decision making from the variety of thumb reconstruction techniques based on patient needs. 4. Have a basic understanding of the various thumb reconstruction techniques discussed. The traumatic amputation of the thumb is an absolute indication for attempted replantation. The profound disability of the hand resulting from absence of the thumb, with loss of pinch and grasp, obliges the surgeon to make every attempt to replant the amputated thumb and preserve hand function. However, not all attempts at replantation result in survival of the amputated portion, and unreconstructable damage to or complete loss of the amputated part may preclude attempted replantation. In such situations, the surgeon must have alternative methods of dealing with the sequelae of thumb loss. This article will discuss nonmicrosurgical and microsurgical techniques for thumb reconstruction.     

Psychological reactions and processes following replantation surgery: a study of 50 patients

Fifty consecutive patients admitted for replantation surgery received a psychiatric evaluation. In 28 percent of the patients there was evidence of preaccident psychopathology. Fifty-four percent of the patients reported a recent stressful life event predating the accident. Fifty-four percent of the patients were assessed as having an adverse postoperative emotional reaction. The presence of preaccident psychopathology, evidence of family dysfunction, and a history of a recent stressful life event were positively linked with an adverse postoperative emotional reaction. In addition, patients with hand or arm replants were significantly less likely to require a psychiatric intervention than patients with leg replants. The psychological processes pertaining to the replantation journey are described in five stages: the preaccident period, the initial response, the stage of uncertainty, the recognition of loss, and acceptance and reintegration. Finally, the role of a liaison psychiatrist on a replantation unit is outlined and further research is strongly urged.     

低分子肝素钙对小血管损伤术后血液流变学影响的临床研究

目的：观察应用低分子肝素钙如何提高断指再植成活率的作用机制,为临床更好的应用低分子肝素钙提供理论基础。方法：通过临床随机对照试验设计,以30例断指再植患者为研究对象,30例健康成人为参照对象。观察30例断指再植患者术前术后不同时段血液流变学指标的变化。结果：断指患者受伤至术后72h血液流变学指标均明显升高,与对照组比较有显著差异（P〈0.01）。低分子肝素钙可以显著降低断指再植患者的血液粘度,改善血液不利于断指成活状态,提高断指成活率,降低其坏死率、致残率。结论：低分子肝素钙,毒副作用小,为防治断指再植术后并发症的一种良药,为临床断指成功再植提供了一种较为理想的治疗方法。     

Replantation versus Prosthetic Fitting in Traumatic Arm Amputations: A Systematic Review

Background

Traumatic arm amputations can be treated with replantation or surgical formalization of the stump with or without subsequent prosthetic fitting. In the literature, many authors suggest the superiority of replantation. This systematic review compared available literature to analyze whether replantation is functionally and psychologically more profitable than formalization and prosthetic fitting in patients with traumatic arm amputation.

Methods

Functional outcome and satisfaction levels were recorded of patients with amputation levels below elbow, through elbow, and above elbow.

Results

Functional outcomes of 301 replantation patients and 172 prosthesis patients were obtained. In the replantation group, good or excellent functional scores were reported in 39% of above elbow, 55% of through elbow, and 50% of below elbow amputation cases. Nearly 100% of patients were satisfied with the replanted limb. In the prosthesis group, full use of the prosthesis was attained in 48% of above elbow and in 89% of below elbow amputation patients. Here, 29% of patients elected not to use the prosthesis for reasons including pain and functional superfluity. In both replantation patients and prosthesis wearers, a below elbow amputation yielded better functional results than higher amputation levels.

Conclusions

Replantation of a traumatically amputated arm leads to good function and higher satisfaction rates than a prosthesis, regardless of the objective functional outcome. Sensation and psychological well-being seem the two major advantages of replantation over a prosthesis. The current review of the available literature shows that in carefully selected cases replantation could be the preferred option of treatment.     

Successful replantation in the face of absent venous drainage: an experimental study

Inadequate venous outflow is the factor most responsible in digital replantation failure and is a common cause of tissue loss in general. An experimental replantation model utilizing the rabbit ear was used to study the extreme example of venous congestion: absent venous drainage in the replanted part. Results of this study support the use of single arterial inflow along with an efferent AV fistula for outflow in the management of replants with absent venous drainage. Potential indications for the use of an efferent arteriovenous fistula in digital revascularization include the following: (1) the finding of distal veins too small to reanastomose, as is often the case in children and at distal levels in adults; (2) preferential destruction of distal venous structures, as commonly seen in degloving or other dorsal injuries; and (3) in the management of postreplant venous thrombosis.     

Rat ear reattachment as an animal model

The external ear of the rat is an excellent model for practicing microsurgical dissection and for the refinement of microvascular anastomoses, techniques that are crucial for microvascular en bloc tissue transfer and replantation. Preparation of the rat ear for replantation requires familiarity with the vascular anatomy and gentle tissue handling with atraumatic dissection of arterial and venous pedicles, steps similarly crucial in raising free flaps for microvascular transfer. The strategy of performing accurate reduction and stabilization of the tubal cartilage prior to vessel repairs, anastomosing the more deeply seated external carotid artery prior to the more superficial posterior facial vein, is as critical to rat ear replantation as for digital reattachment. In addition, the rat ear as compared to other animal models such as the rabbit ear or canine hindlimbs is much less expensive. Compared to the rat hindlimb model, rat ears are much easier to observe, which is a distinct advantage when used as a model for long-term study of replantation, revascularization, or transplantation.     

Traction avulsion amputation of the major upper limb: a proposed new classification, guidelines for acute management, and strategies for secondary reconstruction.

Major replantation of a traction avulsion amputation is undertaken with the goal of not only the reestablishment of circulation, but also functional outcome. This type of amputation is characterized by different levels of soft-tissue divisions involving crushing, traction, and avulsion injuries to various structures. Between 1985 and 1998, 27 cases were referred for secondary reconstruction following amputation of the upper extremity involving both arm and forearm. Replantation was performed by at least 12 qualified plastic surgeons using different approaches and management, resulting in different outcomes. Initial replantation management significantly affects the later reconstruction. For comparing studies and prognostic implications, the authors propose a new classification according to the level of injury to muscles and innervated nerves: type I, amputation at or close to the musculotendinous aponeurosis with muscles remaining essentially intact; type II, amputation within the muscle bellies but with the proximal muscles still innervated; type III, amputation involving the motor nerve or neuromuscular junction, thereby causing total loss of muscle function; and type IV, amputation through the joint; i.e., disarticulation of the elbow or shoulder joint. Some patients required further reconstruction for functional restoration after replantation, but some did not. Through this retrospective study based on the proposed classification system, prospective guidelines for the management of different types of traction avulsion amputation are provided, including the value of replantation, length of bone shortening, primary or delayed muscle or nerve repair, necessity of fasciotomy, timing for using free tissue transfer for wound coverage, and the role of functioning free muscle transplantation for late reconstruction. The final functional outcome can also be anticipated prospectively through this classification system.     

Successful replantation of an amputated nasal tip by microvascular anastomosis

Successful microsurgical replantation of a completely avulsed nasal tip is presented. The result is excellent. The technical challenge involved no sizable veins for drainage. This problem was solved by an artery-to-vein shunting. For facial avulsions, there is nothing superior to the original tissue, and replantation should always be attempted first.     

Ten-digit replantation

A case is presented of replantation of 10 digits at the proximal phalangeal level. Seven digits survived. Osteotomies and flexor tenolysis were done on the right thumb, long, and ring fingers and left index and long fingers 11 months later. A toe-to-hand transfer was done to reconstruct the failed left thumb replantation. Functional and sensory recovery is satisfactory.     

Indices of hexosamine-containing biopolymers in experimental tooth replantation

The experimental findings showed that the content of hexosamine-containing biopolymers, in periodontal tissue increased by 38.23 and 124% conformably over 14 days after replantation of 4 teeth of the dogs. The indices normalized in 28 days of the experiment. Investigated biochemical parameters in the root of replantation tooth, in osseus tissues of alveolus 2nd blood. Changed slightly in dynamics.     

Microsurgical replantation of the amputated nose

A case of successful replantation of the nose is presented. Two arteries and one vein were anastomosed, providing a stable framework for direct revascularization of the amputated nasal segment. This resulted in complete survival of the nose, with an excellent aesthetic result. However, despite successful microsurgical arterial and venous repair, significant postoperative blood loss still occurred as a result of anticoagulation. In cases of the amputation of specialized structures, the improved functional and cosmetic result obtained with replantation must be weighed against the risk of blood-borne disease transmission when postoperative transfusion is required. Recognizing the potential need for postoperative transfusion in these cases is important in allowing the surgeon to exercise appropriate judgment in deciding whether replantation should be performed.     

Successful replantation of lower leg and foot, with good sensibility and function.

The successful replantation of the lower part of a leg with the foot is reported in a 17-year-old boy. Adequate protective sensibility was obtained, and he walks well with a 3-inch lift on that shoe. He is also able to hike, climb, swim, dive, and engage in most normal activities. The pros and cons of leg replantation are considered.     

Saving Amputated Digits: Current Status of Replantation of Fingers and Hands

Since the advent of microsurgery in the 1960''s it has become possible to sucessfully repair vessels as small as 0.5 mm in diameter, which makes the replantation of totally severed digits possible. Some centers have reported 50 to 60 percent survival of completely severed digits and up to 100 percent survival of amputated hands and of partially amputed but otherwise non-viable digits that were reattached. In view of this success, severed members should be considered as potentially replantable.The recommended indications for replantation are: (1) multiple digital amputations at or proximal to the proximal interphalangeal joint; (2) amputation of the thumb; (3) amputation of the wrist or hand; (4) partially attached digits that are non-viable without reattachment.The surviving replanted digits give functional improvement to the hand and prove cosmetically acceptable.     

Successful replantation of an amputated leg in a child.

We report the successful replantation of an amputated leg in a 4-year-old boy. Four years after the replantation, skeletal growth and nerve regeneration were good and he had an excellent recovery of function and appearance. This result was undoubtedly enhanced by his youth, the ideal conditions for nerve repair, and the good preservation of the amputated leg in ice water. Replantation of an amputated lower extermity should be tried if the conditions mentioned above are fulfilled.     

Influence of extended operation time and of occlusal force on determination of pulpal healing pattern in replanted mouse molars

The mechanism regulating the divergent healing processes following tooth replantation is unclear. This study clarifies the relationship between the healing pattern, the time taken for tooth replantation, and the influence of occlusal force. We investigated the pulpal healing process after tooth replantation by immunohistochemistry for 5-bromo-2′-deoxyuridine and nestin and by histochemistry for tartrate-resistant acid phosphatase. The upper right first molar of 3-week-old mice was extracted and repositioned in the original socket immediately or 30 min to 6 h after the operation. We divided the animals into a non-occluded group in which the lower right first molar was extracted and an occluded group without extraction of the counterpart tooth. In control teeth (upper left first molar), the periphery of the coronal dental pulp showed intense nestin-positive reaction. Tooth replantation weakened the nestin-positive reaction in the pulp tissue. On postoperative days 5–7, tubular dentin formation commenced next to preexisting dentin in which nestin-positive odontoblast-like cells were arranged in successful cases. In other cases, bone-like tissue formation occurred in the pulp chamber until day 14. The ratio of tertiary dentin formation was significantly higher in the non-occluded group. The intentionally prolonged time for the completion of tooth replantation induced bone-like tissue formation, expanded inflammatory reaction, or fibrous tissue formation in pulp tissue. Thus, the lack of a proper oxygenated medium is probably decisive for the survival of odontoblast-lineage cells, and occlusal force during and/or after operation worsens the fate of these cells. This work was supported in part by KAKENHI (B) from MEXT, Japan (no. 16390523 to H.O.) and by the Japan-Korea Joint Research Project from JSPS and KOSEF.     

Expanding the limits of composite grafting: a case report of successful nose replantation assisted by hyperbaric oxygen therapy

A successful nose replantation assisted by hyperbaric oxygen therapy is presented, with a brief discussion of the possible mechanisms and a brief literature review of the use of hyperbaric oxygen in tissue preservation and replantation. Although it is not certain that the hyperbaric oxygenation ensured the survival of the replanted nose in this 2-year-old girl, there was documented change in graft appearance during the initial hyperbaric oxygen treatment. A 1-month, 1-year, and 2-year follow-up is included.