1.1 Clinical research data
65 patients with severed fingertips operated in Loudi Central Hospital from January 2014 to November 2018 and in the Third Affiliated Hospital of Southern Medical University from November 2018 to January 2021 were randomly selected. All of them were included in the group, 36 males and 29 females; the age ranged from 1.5 to 56 years, with an average of (31 ± 2) years old. All of the fingers were severed, 44 cases of right hand and 11 cases of left hand. Injury finger categories: 15 cases of thumb, 26 cases of index finger, 12 cases of middle finger, 5 cases of ring finger, 6 cases of little finger. Causes of injury: 38 cases of sharp cutting injuries, 9 cases of chainsaw injuries, 7 cases of strangulation injuries, 7 cases of crush injuries, and 4 cases of bite injuries. According to the Ishikawa classification standard, the distal finger was classified as: Type I (far from the midpoint of the nail) 15 cases ; Type II (nail root to midpoint of nail) 7 cases; Type III (from the root of the nail to 1/2 of the distal interphalangeal joint) 25 cases; Type Ⅳ (from the root of the nail to the proximal half of the distal interphalangeal joint) 18 cases.
The 12 fingers that were not able to find a suitable vein for anastomosis at the distal end were treated with supermicroscopic technique for arterial venous amputated finger replantation as group A; if an anastomosis condition was available, the anastomosis method of the distal segment of the finger was a normal artery, Venous end-to-end anastomosis replantation of 25 fingers as group B; due to unconditional anastomosed vein anastomosis, only unilateral artery anastomosis plus postoperative bloodletting therapy for 9 fingers as group C; finger end segmentation without arteriovenous anastomosis conditions, 19 fingers that could only undergo in situ replantation of the fingertips were regarded as the group D.
All the surgical methods could not be predicted before the operation and need to be determined during the operation. The preoperative doctor in charge introduced the possible options of the amputated finger replantation to each group of patients or parents in detail, and obtained a written informed consent signed by each patient and their parents. There was no significant statistical difference between the groups in various indexes before operation.
1.1.1 Surgery and postoperative treatment process
During the surgical procedure, the operation was performed under a microscope (Moller-Wedel GmbH FS 2012), and the magnification was 26–32 times. The patient was treated with brachial plexus anesthesia or general anesthesia. The affected limb was laid flat on a sterile operating table. At the beginning of the operation, the operating room was kept at a constant temperature of 23 degrees. When the blood vessels were ready for anastomosis, the temperature in the operating room was raised to 28 degrees Celsius. The operation was performed by the surgeon and assistant in pairs, and the assistant cooperated on the opposite side.
First, the upper arm pneumatic tourniquet ("Jinjian JS-B27") was used to inflate the bleeding. The severed fingers were routinely cleaned with normal saline, diluted complex iodine, trimmed and incised, dissected the flexor and extensor tendons and digital nerves at both ends, dissociated the bilateral digital proper arteries and dorsal veins and marked. A 0.8–1.5 diameter Kirschner wire was used to fix the severed phalanx, and an oblique Kirschner wire was added if necessary to prevent rotation. If insertion of flexor or extensor tendon was involved, suture or reconstruction was performed to suture the finger proper nerve.
Arterial blood supply vessels for anastomosis: For the arterial blood supply vessels, the ulnar finger artery was generally selected for thumb, index finger and middle finger, while the radial finger artery was selected for little finger and ring finger. With good elasticity and thick blood vessels, the probability of arterial crisis after anastomosis is low, so they are the preferred arterial vessels. The dominant digital artery was anastomosed with the 10 − 0 to 12 − 0 undamaged silk thread, and the tourniquet was loosened to check the bleeding of the other digital artery at the distal end of the severed finger. If the bleeding was unobstructed, it would be used as the distal blood vessel matching arterial venous. Reinflate the tourniquet to stop the bleeding.
In group A, 12 cases of severed finger distal segment replantation arterial venous vascular anastomosis: the finger artery with smooth bleeding on the non-dominant side of the severed finger were selected, and the adventitia of the 1.5 mm end of the vessel was removed. A vein with a diameter of about 0.3–0.5 mm on the outside of the nail groove on the non-dominant side of the proximal finger was selected as the docking vessel. Hydraulic pressure was applied to enlarge the distal artery and proximal vein diameter, Fig. 1. A 12-0-10-0 non-injury vascular line under a 26–32 times microscope was used to perform an intermittent valgus anastomosis, a strangulation test was performed after the operation to determine the patency of the blood vessel, and check that the fingertips were full and ruddy. If the judgment was not accurate, observed after 10 minutes, there was no dark red blood from the distal end of the acupuncture finger, and the capillary filling test was negative, indicating that the blood supply of the finger was good. Closely monitoring the patient's blood pressure during the operation, and keeping the blood pressure at a systolic pressure greater than 130 mmHg during the anastomosis. After the anastomosis, the skin was loosely sutured to prevent the blood vessels from being compressed, and special care should be taken not to compress the finger artery area when bandaging. The fingertips should be lined to the upper middle of the upper arm with plaster protection to prevent inadvertent movement of the affected limb. Routine anti-tetanus, anti-inflammatory, anti-spasm, and constant temperature treatment were given after the operation.
In group B, 25 cases of finger distal segment replantation surgery were performed with conventional arterial-to-artery and vein-to-vein anastomosis during vascular anastomosis. The other replantation procedures were the same as those in group A. The postoperative related treatment was the same as that of group A.
In group C, 9 cases of finger distal segment replantation surgery did not have proper venous anastomosis and only anastomosed unilateral artery. The other replantation operations were the same as group A. After surgery, they returned to the ward to closely observe the blood supply of the replanted finger and used bloodletting therapy if necessary.. Other related treatments after operation were the same as in group A.
In group D, 19 cases of replanted finger with severed distal segment of the finger had no conditions for anastomosis of the distal artery and proximal vein. Kirschner wires were used to enlarge the medullary cavity, the severed finger was replanted in situ, and hyperbaric oxygen was used after the operation. Hyperbaric oxygen chamber treatment 2 times/d, 2 h/time; other postoperative treatments were the same as group A.
1.1.2 Assess clinical results
(1) The replanted fingers were evaluated. The content of the evaluation included finger capillary filling experiment, the average survival rate of each finger, the length of hospitalization, the number of vascular crises, and partial skin necrosis.
(2) After the operation, the patient was required to return to visit regularly. If the patient had abnormal changes during the recovery at home, he could contact the doctor in time through telephone, WeChat, etc. After 2 years of follow-up, the function of the replanted fingers and the degree of two-point discrimination were determined again, and the patient's satisfaction with this treatment was investigated.
1.1.3 Statistical analysis
SPSS22.0 statistical software package was used for processing. Continuous data were expressed as (± S) and t-test was performed. The count data were described by rate and composition ratio, and χ2 test was used. The test level was 0.05 on both sides of α value.
1.2 Corpse research materials and methods
In January 2022, 10 isolated hand index books were taken from the Department of human anatomy of Southern Medical University. Among them, there were 5 on the left and 5 on the right.
Autopsy finger dissections were performed by two pediatric orthopedic surgeons (15 years and 5 years experience respectively) with microsurgery skills under the same microscope at 8–32 times magnification, carefully dissecting the index books of 10 isolated hands. ①According to the methyl line and the distance of the midpoint of the finger thread as the positioning standard, analyze the relationship between the distribution of the terminal arteriovenous blood vessels available for anastomosis and the two positioning marks. ②To find the matching relationship between the distal finger artery and the proximal vein, so as to determine the conditions of arterial venovenous anastomosis and the optional range of the distal finger. (3) Possible collateral damage, etc.