Domanasiewicz Adam, Jabłecki Jerzy
Limb Replantation Ward, St. Hedwig Hospital in Trzebnica.
Ortop Traumatol Rehabil. 2009 Nov-Dec;11(6):549-61.
Every traumatic amputation of the thumb is an indication for an attempt of replantation. Due to local state of the wound not every case qualifies for this procedure. Such patients may be offered a multi-step salvage reconstruction of the amputated finger; the first step consists of an emergency implantation of the bony phalanx under the skin of the abdominal wall. The osseous graft was covered with skin using a pedicled tubular flap or a "cutaneous pocket". The aim of this paper was to evaluate the effectiveness of this reconstructive method.
Over a period of four years, we operated on 24 patients (22 males, 2 females) aged 17 - 56 years (mean 31.3 yrs); trauma affected the dominant hand in 16 cases (66%); 17 patients (71%) lost their thumbs at the level of IP joint ; in the remaining 7 cases (29%) the amputation was at the level of the MCP joint. In 3 cases with concomitant amputation of the 2nd and 3rd fingers, the grafted structure was the bony phalanx of the index finger. The grafted phalanx, its soft tissues pared off, was joined with the proximal phalanx or the 1st metacarpal bone with two K-wires and then covered with a pedicled tubular flap or implanted to a cutaneous pocket preformed from the abdominal wall. The flap and the "pocket" were cut away on average after 30.2 days. The cutaneous plasty of the finger was performed on average after 11.3 weeks; the sensory island was transferred according to Littler in 18 patients on average 22.2 weeks after the amputation. The evaluation included: osteosynthesis, mobility of the finger (Kapandji's test), pinch-grip strength, touch sensation (filament and discriminatory, temperature sensitivity), esthetics of the finger, and the employment status of the patients.
Failure of losing the graft occurred in 3 patients (12%) and was due to an infection unresponsive to treatment and developing on necrotic flaps. Five patients (21%) developed marginal necrosis within the fragments of the cut off flaps requiring cutaneous plasty; an inflammation of the recipient site occurred in 5 cases (21%). 18 patients (75%) of the patients turned up for the distant follow-up on average 13.2 months after the accident (range 11 - 28 mths). 16 patients (89%) had good bone union; in 2 cases the distal part of the graft had been resorbed. All of the patients were able to touch the pseudo-ball of the thumb with the 5th finger. The strength of the pinch-grip on average reached 3.3 kG (range 1.8 - 6.2 kG), which equals to 55% (range 36 - 78%) of the uninjured hand. Touch sensation was satisfactory in 16 patients (89%) (blue filament), reduced in 2 (11%); 6 patients (33%) showed two-point discrimination in the range of 10 to 15 mm. The esthetical result of the thumb was assessed as good in 13 (72%) and satisfactory in 5 patients (28%). Fifteen patients (83%), 9 blue collar workers and 6 farmers, continued with their occupations.
The autograft of the amputated phalanx is a valuable reconstructive method for a selected group of patients.
每例拇指外伤性截肢均提示有进行再植尝试的指征。但由于伤口局部情况，并非每例患者都适合该手术。对于此类患者，可提供一种多步骤的断指挽救性重建方法；第一步是将指骨紧急植入腹壁皮下。骨移植块用带蒂管状皮瓣或“皮袋”覆盖皮肤。本文旨在评估这种重建方法的有效性。
在四年时间里，我们对24例患者（22例男性，2例女性）进行了手术，患者年龄在17至56岁之间（平均31.3岁）；16例（66%）患者的优势手受伤；17例（71%）患者的拇指在指间关节水平离断；其余7例（29%）患者的截肢发生在掌指关节水平。在3例伴有示指和中指同时离断的患者中，移植结构为示指的指骨。将去除软组织的移植指骨用两根克氏针与近端指骨或第一掌骨连接，然后用带蒂管状皮瓣覆盖或植入由腹壁预制的皮袋中。皮瓣和“皮袋”平均在30.2天后切除。手指的皮肤成形术平均在11.3周后进行；18例患者平均在截肢后22.2周根据利特勒法转移感觉岛。评估内容包括：骨愈合情况、手指活动度（卡潘迪试验）、捏握力、触觉（细丝和辨别觉、温度觉）、手指美观度以及患者的就业状况。
3例患者（12%）出现移植失败，原因是治疗无效的感染并发生在坏死皮瓣上。5例患者（21%）在切断皮瓣的碎片内出现边缘性坏死，需要进行皮肤成形术；5例患者（21%）出现受区炎症。18例患者（75%）在事故后平均13.2个月（范围11至28个月）前来进行远期随访。16例患者（89%）骨愈合良好；2例患者移植骨的远端部分出现吸收。所有患者均能用小指触摸到拇指假球。捏握力平均达到3.3千克（范围1.8至6.2千克），相当于健侧手的55%（范围36%至78%）。16例患者（89%）触觉满意（蓝色细丝试验），2例患者（11%）触觉减退；6例患者（33%）两点辨别觉在10至15毫米范围内。13例患者（72%）拇指的美观效果评估为良好，5例患者（28%）为满意。15例患者（83%）继续从事他们的职业，其中9名蓝领工人和6名农民。
对于特定患者群体，截肢指骨的自体移植是一种有价值的重建方法。
