摘要
目的:(1)探索断肢寄养的适合应用对象和方式,确定寄养的适宜受区部位和回植时的血运重建方式;(2)获得暂时性异位断肢寄养再回植术的系统理论与方法,提高应用成功率,为创伤领域提供处理这种复杂病例的指导性原则和技术依据;(3)探索异位断肢寄养的肢体神经肌肉功能恢复与改善的方法,为进一步深入研究断肢寄养过程中有效地促进断肢骨骼肌的损伤神经再生并恢复神经功能提供理论支持。
方法:(1)断肢骨骼肌异位寄养动物模型的建立及神经功能恢复的实验研究:①取鼠龄8个月的健康雄性Sprague-Dawley大鼠60只,随机分为三组:实验对照组,原位再植组,异位移植寄养组。实验对照组:切断支配右侧股薄肌的闭孔神经,造成肌肉失神经支配;原位再植组:将右侧股薄肌完全切取下来,再回植于原位,闭孔神经植入肌肉:异位移植寄养组:将右侧股薄肌完全切取下来后,移植寄养于左侧股部,闭孔神经植入肌肉。术后25周,采用神经肌电图仪收集各组的神经电生理信息。观察股薄肌大体形态并测量肌湿重。②取鼠龄8个月的健康雄性Sprague-Dawley大鼠90只,随机分为三组:实验对照组,运动神经吻合组,感觉神经吻合组。将右侧股薄肌切取下来并寄养于左侧股部,实验对照组:离断的闭孔神经不做处理。运动神经组:离断的闭孔神经与左侧股神经分支吻合。感觉神经组:离断的闭孔神经与左侧隐神经吻合。术后25周。观察股薄肌大体形态并测量肌湿重,组织学观察肌肉与神经的结构。(2)暂时异位寄养的相关应用解剖,影像和组织学研究:①30具经福尔马林固定的中国成人人体标本,男女各半。随机选取30位正常成年人(志愿者),男女各半。对标本行解剖学研究,暴露,观察并测量四肢的主要血管外径,厚度和内径,并用超声影像学测量活体四肢主要动脉内径,与标本内径相比较。②随机选取兔30只,制作右后肢小腿中段切割性断肢模型。肢体离断后近端动脉旷置三周后,观察断肢近端血管的形态和组织学变化。(3)断肢暂时性异位寄养再回植术的应用研究:选择无一期再植条件的11例断肢患者,所有患者均是断端毁损严重,无可供吻合的血管和组织支架,同时合并出血性休克或多脏器损伤等全身创伤使机体不能耐受长时间再植手术。采用暂时异位寄养的方法,将断肢清创后同自身其它部位动静脉吻合,暂时异位寄养成活。全身状态平稳和离断肢体近端条件允许时,再将断肢回植于原位,随访预后。
结果:(1)断肢骨骼肌异位寄养动物模型的建立及神经功能恢复的实验研究:①实验对照组股薄肌呈现失神经电位,异位移植寄养组与原位再植组相比,神经肌肉电位的潜伏期、波幅和神经传导速度等指标均无显著性差异(P＞0.05)。实验对照组股薄肌萎缩明显,肌湿重为158.0±19.3 mg。异位移植寄养组与原位再植组股薄肌萎缩不明显,肌湿重分别为509.6±14.5mg和516.8±12.7mg,均大于实验对照组(P＜0.05),两组无显著性差异(P＞0.05)。②实验对照组股薄肌萎缩明显,肌湿重为204.0±15.3mg。运动神经吻合组和感觉神经吻合组股薄肌萎缩不明显,肌湿重分别为394.8±12.9mg和389.2±13.5mg,均大于实验对照组(P＜0.05),两组无显著性差异(P＞0.05)。感觉和运动神经组的组织学观察均发现神经再生的形态学证据。(2)暂时异位寄养的相关应用解剖,影像和组织学研究:①人体前臂和小腿均存在两套供血血管,前臂和小腿的主要血管解剖位置恒定、表浅,血管口径较粗,直接起于主干血管,而且在手术操作中暴露容易。四肢左右侧血管外径,内径和管壁厚度等数据无显著性差异,对活体与标本的动脉内径进行比较,无统计学差异。②断端近侧的血管,中层平滑肌收缩,管径变细,管口缩小。动脉直径平均为正常动脉直径的50%。内弹力层不对称,中层平滑肌变薄或厚薄不均。(3) 11例断肢经二期回植后均完全存活。断肢经随访,受伤的肢体,上肢保护性感觉开始恢复,肌肉弹性佳,外观无明显萎缩,部分患者可从事一些日常工作;下肢恢复正常长度,足底感觉开始恢复,患者可以开始行走。
结论:(1)“断肢暂时性异位寄养再回植术”是创伤领域挽救特殊疑难断肢的一种新技术,能有效保存肢体的完整和功能,减少致残率。(2)复杂断肢毁损严重,无可供吻合的血管和组织支架,同时合并出血性休克、多脏器损伤等全身创伤使机体不能耐受长时间再植手术,以上为断肢暂时性异位寄养再回植术的临床应用“适应症”。(3)对侧健康肢体(前臂或小腿)为断肢异位寄养的最佳受区部位。二期回植重建第二套血供的理论与方法能有效地保证肢体回植过程的成功率。(4)异位移植寄养过程中,运动神经植入、运动或感觉神经吻合均能有效地减轻断肢骨骼肌失神经性萎缩,有助于断肢的保护性感觉和神经肌肉功能的恢复。
Objective (1) To study the applicable object and methods of "Temporary Ectopic Implantation of Amputated Limb", to search the suitable recipient site and the ideal method of implantation in the second stage. (2) To get the systemic theory and technique of "Temporary Ectopic Implantation of Amputated Limb",to provide the skill supports to lift the rate of success for application.(3) To study the methods of reinnervation after ectopic transplantation of skeletal muscle of amputated limbs, to provide the theory support of such kainds of researchs in future.
Methods (1) The study of reinnervation after ectopic transplantation of skeletal muscle of amputated limbs.①60 Sprague-Dewley male rats which were 8 months old were randomly divided into 3 groups: Experimental Control group, Original Implantation group, and Ectopic transplantation group. Experimental Control group: cut off obturator nerve which controlled right gracilis. Original Implantation group: cut off the right gracilis, replanted it to its original site and implanted the obturator nerve to the muscle. Ectopic transplantation group: cut off the right gracilis, transplanted the muscle to the left leg and implanted the obturator nerve to the muscle. After 25 weeks, colleted the neurophysiological information through Electromyography and measured the weight of the muscle.②90 Sprague-Dewley male rats which were 8 months old were randomly divided into 3 groups: Experimental Control group, motor reinnervation group, sensory reinnervation group. Cut off the right gracilis, transplanted the muscle to the left leg , Experimental Control group: no reinnervation was performed onthe obturator nerve, sensory reinnervation group: obturator nerve was coapted with recipient saphenous nerve, motor reinnervation group: obturator nerve was coapted with femoral nerve motor branch. After 25 weeks, measured the weight of the muscle, histological examination. (2) Correlative researches of applying anatomy,image and tissue about "Temporary Ectopic Implantation of Amputated Limb".①30 specimens of Chinese adult (half of them are men's specimen,half of them are women's specimen),30 Chinese adults who are volunteers randomly (half of them are men,half of them are women). Dessect the vessels, measure the external perimeter, thickness and inner perimeter of the vessels, measure the inner perimeter of the vessels on alive body with supersonic image,contrast the inner perimeter between alive body and specimen.②Select 30 rabbits randomly,cut off the middle of right posterior limb to make amputated model, after 3 weeks,observe the vessel's morphological and tissue change of approximate end of extremity. (3)The applying research of "Temporary Eetopic Implantation of Amputated Limb" . Performe 11 cases of temporary ectopic implantation of amputated limbs. All of amputations were identified with combined extensive segmental injuries in the proximal site of amputations and closed head injury, abdominal and thoracic injuries, and serious blood loss. The amputated parts were implanted onto the contra-lateral healthy extremities and survived. The implanted parts were then harvested and replanted onto theanatomic positions and follow up.
Results (1) The study of reinnervation after ectopic transplantation of skeletal muscle of amputated limbs.①The potential without control of the nerve existed in experimental control group, no dominant differences about latency , amplitude and conduct velocity existed between original implantation group and ectopic transplantation group(P > 0.05).The atrophy of gracilis was dominant in experimental control group, the weight of the muscle was 158.0±19.3 mg. The weight of the muscle was 509.6±14.5mg in ectopic transplantation group, 516.8±12.7mg in original implantation group, no dominant difference existed in two groups(P > 0.05). The weight of the muscle in original implantation and ectopic transplantation group was larger than the weight in experimental control group(P < 0.05).②The atrophy of gracilis was dominant in experimental control group, the weight of the muscle was 204.0±15.3 mg. The weight of the muscle was 394.8±12.9mg in motor reinnervation group, 389.2±13.5mg in sensory reinnervation group, no dominant difference existed in two groups(P > 0.05). The weight of the muscle in both motor reinnervation group and sensory reinnervation group were larger than the weight in experimental control group(P < 0.05).The evidences of reinnervation were found in histological examination. (2) Correlative researches of applying anatomy,image and tissue about "Temporary Eetopic Implantation of Amputated Limb".①There are double blood supply systems in human's forearm and leg.The site of vessels in forearm and leg are invariablen, superficial and easy to be found. The caliber of the vessel is thick.No dominant difference is found between left and right limb about the external perimeter,thickness and inner perimeter of the vessels. No dominant difference is found between alive body and specimen about inner perimeter of the vessels.②The artery of approximate end of extremity become thin and the middle layer of smooth muscle become atrophy.The average diameter of the artery is 50% of the normal artery. The inner elastic layer is asymmetry.(3) The applying research of "Temporary Eetopic Implantation of Amputated Limb". All of implantation and staged replantation survived. After following-up, all of staged replanted parts restored protective sensation, and partial motor function was recovered in some cases.
Conclusion (1) "Temporary ectopic implantation of the amputated limbs" provides an alternative for the salvage of amputated extremities under these special circumstances. It can save the limb's integrity and function, relieve the rate of deformity.(2)Devastating segmental injuries of the proximal extremities, and the conditions of the amputation wounds, combined severe complex injuries and the traumatic shock are also indicated for temporary ectopic implantation of the amputated part, since the patient with critical condition can not tolerate a long procedure of replantation. Above mentions are the applying indications of "Temporary ectopic implantation of the amputated limbs".(3) Contra-lateral healthy extremity is an ideal recipient site for temporary ectopic implantation, from which cross-arm or cross leg flap can be designed to protect the blood supply to the second staged replantation and improve the replantation. (4)Motor nerve implantation, motor or sensory nerve anastomosis after ectopic transplantation of skeletal muscle could prevent the atrophy of the muscle and resume partial function of nerve.
引文
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