Krylov V S, Milanov N O, Peradze T Y, Borovikov A M, Shilov B L
Department of Microsurgery, All Union Research Center of Surgery, USSR Academy of Medical Sciences, Moscow.
J Reconstr Microsurg. 1987 Jul;3(4):321-6. doi: 10.1055/s-2007-1007002.
Replantation in the lower leg, although technically feasible, still remains a complicated clinical issue in terms of the decision-making process. In children, a limb salvage or replant procedure would seem preferable; however, in crush amputations from railroad injury, a very severe trauma, difficulties in treatment should be thoroughly weighed against prosthetic possibilities: for example, only a fair or good functional outcome would justify an attempt to replant a severed shin. Unfortunately, the outcome in most cases is unpredictable at the time of initial evaluation, and even during the replantation procedure itself. To facilitate prognosis, the authors determine four typical variants of replantation course and outcome, based on local patient conditions, although they stress that no clear indications for replantation vs. prosthesis can be derived from the variants listed. Rather, general guidelines for the surgeon's decision at a very early stage of treatment are presented. Choice of procedure and tactics cannot be determined once and for all, because the prognosis for functional outcome can change during the course of treatment. Among a few well-defined situations are clean amputations (replantation is indicated) and traumas with very extensive crushing of the whole lower leg (replantation is contraindicated). In the majority of cases, replantation is a worthwhile attempt, but this does not imply that a replanted extremity must be preserved at any cost. The surgeon must consider the possibility of re-amputation, in case of an unfavorable variant in the postoperative course. A successful case of replantation, involving two lower leg railroad amputations in a child, is presented.
小腿再植虽然在技术上可行，但在决策过程中仍然是一个复杂的临床问题。对于儿童来说，保肢或再植手术似乎更可取；然而，对于铁路事故导致的挤压离断伤这种非常严重的创伤，在决定治疗方案时应充分权衡治疗的困难与安装假肢的可能性：例如，只有预期功能恢复良好或尚可，才值得尝试再植离断的胫骨。不幸的是，在初次评估时，甚至在再植手术过程中，大多数情况下的预后都是不可预测的。为了便于判断预后，作者根据患者的局部情况确定了再植过程和结果的四种典型类型，不过他们强调，从所列类型中无法得出再植与安装假肢的明确指征。相反，本文给出了外科医生在治疗早期阶段决策的一般指导原则。手术方式和策略的选择不能一劳永逸地确定，因为功能预后在治疗过程中可能会发生变化。在一些明确的情况下，如整齐离断伤（适合再植）和整个小腿广泛挤压伤（禁忌再植）。在大多数情况下，再植是一次值得尝试的手术，但这并不意味着再植肢体必须不惜一切代价保留。外科医生必须考虑到术后出现不利情况时再次截肢的可能性。本文还介绍了一例儿童小腿铁路离断伤再植成功的病例。
