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Distal Digit Replantation with an Efferent AV Anastomosis for Absent Venous Drainage

無可用靜脈斷指之再接植替代方法-動靜脈側流術

摘要


遠端手指截肢在手外傷中佔了相當大的比例。如果手指截肢部位在指甲弧影(lunula)的近端,更應該考慮接植斷指,因為沒有其它方法可以挽救指甲的存活。斷指接植時,有時會遇到在斷指上無法找到可用之靜脈。傳統上有很多種方法可以解決這種困境,例如單一動脈接合,血蛭引流,指甲旁切開引流,指甲剝除術……等。本文提出四個遠端手指截肢的病例,由於在斷指無法找到可用之靜脈,我們使用斷指的對側動脈,經由一段移植靜脈(vein graft)接在近端殘肢(stump)的靜脈,以動靜脈側流(Av anastomosi)提供回血引流。一開始,接植的部位呈現粉紅色,其溫度均高於32℃。然而,四例中有三例於術後的第2到第4天,發現接植的手指溫度較低,頻色較紫。第5天後,溫度頻色均恢復正常。一例有小部份表皮壞死,最後自然癒合,不需補皮。所有的四個病例均無耐冷不良(cold intolerance)的反應,兩點辨別(two-point discrimination)平均可以到7公厘。半年後返診,接植的部位均較健側手指稍小。病人對於外觀及功能恢復均滿意。此動靜脈側流術,提供斷指接植無法找到可用之靜脈時的替代方法。指尖旣存的動靜脈側流系統,可以讓靜脈血通向動脈,並經由此動靜脈側流流向指背靜脈系統,是此手術方法可行的可能機轉。

關鍵字

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並列摘要


Distal digit amputation is a common injury of hand. If the amputation level is proximal to the lunula, replantation should be considered, since no other procedure will salvage the nail. During fingertip replantation, it is difficult to find an available vein on the amputee. Several methods have been provided to solve the problem including one artery anastomosis, leeches, paraungual incision…… etc. In this report, the contralateral digital artery was utilized to obtain venous drainage in all cases. The artery was anastomosed to the dorsal vein of the stump with a vein graft. Initially, the replantated part showed pinkish color with temperature above 32℃. Nevertheless, in 3 of the 4 cases, the replantated digits became cyanotic and cold with temperatures of 29.5-31.5℃ starting from the second to the fourth post-operative day. However, the color and temperature recovered after the fifth post-operative day. In one case, a small amount of necrosis was encountered which healed spontaneously without skin grafting. All 4 cases showed slightly atrophic appearance during follow up. No cold intolerance was noted. Two-point discrimination was 7 mm on average. These patients were very satisfied with the appearance and functional results. The efferent AV anastomosis provides an important option when no vein is available for distal digital replantation. Existing shunting systems of the fingertip which then provide channels for drainage may be the possible mechanism behind the success of this alternative method of anastomosis.

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