Chen Yi-Chieh, Chan Fuan Chiang, Hsu Chung-Chen, Lin Yu-Te, Chen Chien-Tzung, Lin Chih-Hung
Department of Plastic & Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Linkou, Taiwan.
Ann Plast Surg. 2013 Mar;70(3):284-8. doi: 10.1097/SAP.0b013e3182321b81.
Replantation of amputated fingertips is a technical challenge, as many salvage procedures fail because no suitable vein in the fingertip is available for anastomosis. In this study, we examined our experience in fingertip replantation in cases without venous anastomosis with our established fingertip replantation treatment protocol.
Between August 2002 and August 2010, a retrospective study examined all patients who had undergone fingertip replantation at Chang-Gung Memorial Hospital. All the patients (n = 24) suffered from complete digital amputations at or distal to the interphalangeal joint of the thumb, or distal to distal interphalangeal joint of the fingers. A total of 30 fingertips that were salvaged by microsurgical anastomosis of the digital arteries but not of digital veins were included in this study. On satisfactory arterial anastomosis, a 2-mm incision was made over the fingertip with a number 11 Scalpel blade, and 0.1 to 0.2 mL heparin (5000 IU/mL) was injected subcutaneously around the incision immediately and once per day thereafter to ensure continuous blood drainage from the replanted fingertip. None of the replanted nail plate was removed, and no medical leeches were used. The perfusion of the replanted digits and patient's hemoglobin level were closely monitored. The wound bleeding was maintained until physiologic venous outflow was restored.
Of 30 fingertips, 27 (90%) replanted fingertips survived. The average length needed for maintaining external bleeding by chemical leech was 6.8 days (range, 5-10 days). Twelve patients (including a 2-year-old child) received blood transfusions. The average amount of blood transfusion in the 23 adults was 4.0 units (range, 0-16 units) for each patient or 3.29 units (range, 0-14 units) for each digit. A 2-year-old child received 100 mL blood transfusion or 50 mL for each digit.
This study showed that a protocol that promotes controlled bleeding from the fingertip is essential to achieve consistent high success rates in fingertip replantation. The protocol is safe and reliable, as it avoids the use of medical leeches and the removal of nail plate from the replanted finger. However, full informed patient consent must include the potential need for transfusion and extended hospital stay.
断指再植是一项技术挑战，因为许多挽救手术失败是由于指尖没有合适的静脉可供吻合。在本研究中，我们依据已确立的指尖再植治疗方案，考察了在无静脉吻合情况下进行指尖再植的经验。
2002年8月至2010年8月期间，一项回顾性研究调查了所有在长庚纪念医院接受指尖再植的患者。所有患者（n = 24）均为拇指指间关节或手指远侧指间关节以远的完全离断伤。本研究共纳入30个通过显微吻合指动脉但未吻合指静脉而挽救的指尖。在动脉吻合满意后，用11号手术刀片在指尖做一个2毫米的切口，立即在切口周围皮下注射0.1至0.2毫升肝素（5000国际单位/毫升），此后每天注射一次，以确保再植指尖持续引流血液。所有再植的指甲板均未移除，也未使用医用水蛭。密切监测再植手指的灌注情况和患者的血红蛋白水平。维持伤口出血，直到生理性静脉回流恢复。
30个指尖中，27个（90%）再植指尖存活。通过化学水蛭维持外部出血所需的平均时间为6.8天（范围5 - 10天）。12例患者（包括一名2岁儿童）接受了输血。23名成年人中，每位患者的平均输血量为4.0单位（范围0 - 16单位），每个手指的平均输血量为3.29单位（范围0 - 14单位）。一名2岁儿童接受了100毫升输血，即每个手指50毫升。
本研究表明，促进指尖可控出血的方案对于在指尖再植中取得持续的高成功率至关重要。该方案安全可靠，因为它避免了使用医用水蛭和从再植手指上移除指甲板。然而，必须让患者充分知情同意，其中应包括潜在的输血需求和延长住院时间。
