Reconstructive Microsurgery, Clínica Cavadas, Valencia, Spain.
J Plast Reconstr Aesthet Surg. 2009 Oct;62(10):1321-5. doi: 10.1016/j.bjps.2008.04.027. Epub 2008 Jul 22.
The sequence of repair of structures in macroreplantation surgery is important, since it has a direct influence on ischaemia time, blood loss and technical accuracy. Different sequences have been recommended in the literature. A uniform order of repair was used in a series of macroreplants, performing the arterial repair at the end of the procedure. A total of 341 parts were replanted in 249 patients. Of these, 28 cases (27 patients) were amputations proximal to the wrist. The sequence of repair was temporary catheter arterial shunt for 10-15 minutes, debridement, bone, musculotendons, veins and dorsal skin, nerves, arteries and volar skin. Fasciotomies were performed only if primary ischaemia time had been over 6 hours. A 100% survival rate was achieved. Primary ischaemia time was less than 6 hours in all cases but two. Fasciotomy was performed only in these two patients. Infection rate was 10% (three cases). Soft-tissue necrosis requiring free flap coverage occurred in four cases (14%). In these complicated cases (24%), salvage rate was 100%. Mean operative time was 240 minutes. Functional results according to Chen's criteria were grade I in six cases, grade II in nine, grade III in 13, and no patients with grade IV. Temporary catheter arterial perfusion reduces ischaemia time and permits an artery-last sequence. This may reduce blood loss, permits an accurate repair of non-vascular structures, and shortens operative time.
再植手术中结构修复的顺序很重要，因为它直接影响缺血时间、失血量和技术精度。文献中推荐了不同的顺序。在一系列的宏观再植中，采用了统一的修复顺序，在手术结束时进行动脉修复。共有 341 个部位在 249 名患者中进行了再植。其中，28 例（27 名患者）为腕部近端截肢。修复顺序为临时导管动脉转流 10-15 分钟，清创，骨，肌肉肌腱，静脉和背侧皮肤，神经，动脉和掌侧皮肤。仅在原发性缺血时间超过 6 小时时才进行筋膜切开术。达到了 100%的存活率。所有病例的原发性缺血时间均小于 6 小时，但有两例外。这两例患者仅进行了筋膜切开术。感染率为 10%（三例）。有四例（14%）发生软组织坏死，需要游离皮瓣覆盖。在这 24 例复杂病例中（24%），抢救成功率为 100%。平均手术时间为 240 分钟。根据 Chen 的标准，功能结果为一级 6 例，二级 9 例，三级 13 例，无四级患者。临时导管动脉灌注可减少缺血时间，并允许进行动脉最后修复。这可以减少失血量，允许对非血管结构进行准确修复，并缩短手术时间。
