本文選題：再植術(shù)　切入點(diǎn)：靜脈危象　出處：《河北醫(yī)科大學(xué)》2015年碩士論文

【摘要】：目的:在臨床中,斷指再植術(shù)后出現(xiàn)血管危象,尤其是靜脈危象時(shí),治療較為困難,再植指壞死率較高。本研究旨在選擇兩種臨床療效較為確切的外科靜脈皮瓣進(jìn)行手術(shù)治療,解決再植術(shù)后靜脈危象問(wèn)題,并對(duì)所述兩種手術(shù)方法進(jìn)行臨床對(duì)照分析,以期選擇出符合臨床規(guī)范的手術(shù)方式,應(yīng)用于臨床。方法:自2013年7月至2014年12月,選定河北省滄州中西醫(yī)結(jié)合醫(yī)院收治的手指離斷傷患者,均為單指離斷傷,經(jīng)再植術(shù)后出現(xiàn)靜脈危象者,28例患者28指斷指作為研究對(duì)象。本組患者再植術(shù)后2~72 h出現(xiàn)靜脈危象經(jīng)保守治療無(wú)效,選擇損傷平面位于遠(yuǎn)指間關(guān)節(jié)至指蹼水平者納入組內(nèi),行知情同意告知后,隨機(jī)分為兩組,每組14指。兩組28例患指均由同一組經(jīng)專(zhuān)業(yè)培訓(xùn)的術(shù)者及助手實(shí)施手術(shù),第一組帶蒂鄰指靜脈皮瓣組于術(shù)中切除再植指指背炎性水腫皮緣及栓塞靜脈段后,切取相鄰手指背側(cè)包含至少2條靜脈的帶蒂皮瓣轉(zhuǎn)位至再植指指背區(qū),該皮瓣長(zhǎng)度約4.0~4.5cm,寬度約1.2~1.5cm。將相鄰手指皮瓣靜脈與再植指指背靜脈吻合,供區(qū)植全厚皮片,加壓打包。術(shù)后抗炎抗凝抗痙攣治療,斷指成活后,鄰指皮瓣四周斷蒂,行功能鍛煉。第二組游離靜脈皮瓣組于前臂屈側(cè)或手(指)背選擇有兩條并行靜脈的部位進(jìn)行切取,兩條靜脈需包含在游離靜脈皮瓣的縱軸上且平行分布,皮瓣大小為1.5*1.2~1.5*2.0cm,在10倍顯微鏡下將游離靜脈皮瓣嵌入缺損部位,皮瓣不倒置。其中一條靜脈干與再植指指背遠(yuǎn)近端的靜脈端端吻合,另一條靜脈干近端結(jié)扎,遠(yuǎn)端與非優(yōu)勢(shì)側(cè)或未吻合的指動(dòng)脈遠(yuǎn)斷端端端吻合。供區(qū)直接縫合,無(wú)需斷蒂。于術(shù)中記錄兩組手術(shù)方式各自所用時(shí)間(包括患指的清創(chuàng),皮瓣的切取,供區(qū)的處理以及血管吻合);術(shù)后觀察患指血運(yùn)情況,兩組轉(zhuǎn)移或移植創(chuàng)面皮瓣的顏色,飽滿度等指標(biāo)。兩組指體的外觀分析評(píng)價(jià)方法按照中華醫(yī)學(xué)會(huì)手外科學(xué)會(huì)上肢部分功能評(píng)定試用標(biāo)準(zhǔn)評(píng)定和密歇根手調(diào)查問(wèn)卷(MHQS)評(píng)定表對(duì)兩組進(jìn)行對(duì)照分析。計(jì)量資料均采用均數(shù)±標(biāo)準(zhǔn)差表示,兩組間比較采用單因素方差分析,方差不齊時(shí)應(yīng)用對(duì)方差進(jìn)行校正的Welch方法,所有數(shù)據(jù)用SPSS 19.0軟件統(tǒng)計(jì)處理,檢驗(yàn)水準(zhǔn)α=0.05。結(jié)果:1兩組手術(shù)時(shí)間對(duì)照分析:帶蒂鄰指靜脈皮瓣組手術(shù)時(shí)間為64±4.80分鐘;游離移植靜脈皮瓣組手術(shù)時(shí)間平均82±3.60分鐘。兩組手術(shù)時(shí)間比較,P0.05,兩組有顯著性差異。2成活情況對(duì)照分析:帶蒂鄰指靜脈皮瓣組完全成活11例,痂下愈合2例(多因淺表皮膚水泡破潰形成),部分壞死1例;游離移植靜脈皮瓣組完全成活7例,痂下愈合5例,部分壞死2例。部分壞死病例均經(jīng)植皮或局部皮瓣轉(zhuǎn)移修復(fù)后成活。兩組手術(shù)成功率比較,P0.05,兩組有顯著性差異。3臨床療效的術(shù)后比較:術(shù)后隨訪2~12個(gè)月,平均6.7個(gè)月,所有病例均接受隨訪,無(wú)脫落病例。根據(jù)中華醫(yī)學(xué)會(huì)手外科學(xué)會(huì)上肢部分功能評(píng)定試用標(biāo)準(zhǔn)評(píng)定和密歇根手調(diào)查問(wèn)卷(MHQS)評(píng)定表,帶蒂鄰指靜脈皮瓣組術(shù)后感覺(jué)測(cè)定,優(yōu)10例,良3例,中1例;活動(dòng)度測(cè)定(TAM)優(yōu)11例,良3例;無(wú)觸痛13例,有觸痛1例;供區(qū)愈合情況,優(yōu)12例,良2例。游離移植靜脈皮瓣組感覺(jué)測(cè)定,優(yōu)7例,良5例,中2例;活動(dòng)度測(cè)定(TAM)優(yōu)10例,良4例;無(wú)觸痛11例,有觸痛3例;供區(qū)愈合情況,優(yōu)12例,良2例。兩組手術(shù)臨床療效比較,P0.05,兩組差別有統(tǒng)計(jì)學(xué)意義。結(jié)論:1帶蒂鄰指靜脈皮瓣的外科方法不僅用健康的皮膚覆蓋了缺損部位,與此同時(shí)也修復(fù)了再植指的靜脈回流,相對(duì)來(lái)說(shuō),手術(shù)較實(shí)用,安全和簡(jiǎn)便,但是需二次斷蒂,對(duì)相鄰手指有輕度功能及美觀影響。2游離移植靜脈皮瓣的臨床應(yīng)用效果較好,供區(qū)可直接閉合,但對(duì)顯微外科技術(shù)要求較高,且因血供為非生理性動(dòng)脈血供,故皮瓣壞死率高,術(shù)后皮瓣有不同程度的回縮,成活質(zhì)量較差,故游離靜脈皮瓣可在特殊病例中選用。3臨床上單指再植術(shù)后發(fā)生的靜脈危象,外科皮瓣選擇帶蒂鄰指靜脈皮瓣療效更佳。
[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 ,騫沖潎6.7涓湀,鎵，

本文編號(hào)：1723671