Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 405 - файл
.pdf
80
2 Anatomy oftheHand andFoot
of the recipient site. The metacarpophalangeal joint is xed
at the exion position of 20°–30° by using Kirschner wire or
cross steel wire.
Reconstruction of blood circulation: Anastomosis of
blood vessels of toe and nger (such as replantation of a severed nger), adjusting the tension of blood vessels, and ne
anastomosis of blood vessels and nerves under a
microscope.
Postoperative treatment: (1) Blood circulation should be
observed according to the requirements of tissue transplantation; (2) Routine microsurgery treatment; (3) Gypsum support should be xed for 6–7weeks, and passive functional
exercise should be begun after Kirschner wire is removed. (4)
Tendonolysis should be performed when necessary.
Announcements
The following points should be noted in clinic: (1) Pay attention to the xed position of the graft joint to prevent rotation
and angulation deformity; (2) If the ap is carried at the same
time for transplantation, the position and size of the ap
should be designed to prevent the rotation deformity of the
graft joint caused by the wrong position of the ap and the
blood circulation crisis of the transplanted tissue caused by
the small ap; (3) Preoperative surgery should be carefully
designed, and the vascular conditions in the recipient site and
donor site should be carefully detected with Doppler, and the
blood circulation reconstruction method should be designed
according to the vascular conditions. (4) Metatarsophalangeal
joint transplantation in children, the epiphysis should be
included in to avoid damage, so as not to affect joint development; (5) Note that the diseased bone in the recipient site
should be completely removed, otherwise bone nonunion is
easy to occur after transplantation. (6) Vascular branches are
ligated thoroughly to prevent postoperative bleeding and
form hematoma to compress blood vessels.
Preoperative Treatment forFinger
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Reconstruction
3
Abstract
Indications for nger reconstruction are expanding while
contraindications are shrinking with the development of
comprehensive ability and technical level of microsur-
geon with their unremitting exploration and efforts and
the success rate remains very high. Excellent medical
techniques, cooperation of patients, and reasonable func-
tional exercise would reduce the disability rate and
improve quality of life. But patients with incomplete n-
gers especially the thumb missing is still common in
clinic, which would seriously affect the appearance and
function of hand, and even be severe psychological
trauma. For now, the success rate is above 95% for not
only simple reconstruction with toe replantation but also
complete reconstruction of nger with different parts.
Relative to nger replantation, expectations of patients
and demands for medical staff would be higher. So how to
complete nger reconstruction with present quality, the
prerequisite for success is sufcient preoperative treat-
ment to master surgical indications contraindications, and
complete preoperative assessment, preoperative examina-
tion, design of operation plan, corporation of surgeon, OR
team, and patients are also essential.
Keywords
Preoperative treatment · Finger reconstruction
We conclude as follows (according to our experience and
literature):
3.1.1 Systemic Assessment
The general condition of patients should be assessed by complete physical examination, and laboratory tests to exclude
systemic diseases that cannot tolerate surgery such as severe
organic heart disease, liver, kidney dysfunction, and so on;
exclude hematologic disorders and lower extremity vascular
disease such as hemophilia, thromboangiitis, and so on;
exclude local infectious disease such as fungal infection of
foot, etc.; exclude the history of trauma that affects operation
such as severe burns, scalds, frostbite, etc.; exclude mental
and emotional disorders such as self-mutilation, propensity
for violence, schizophrenia, depressive disorder, etc.
3.1.2 Assessment ofFinger Stump
Assessment of nger stump is very important for design of
reconstruction and function recovery since the structure of hand
is delicate and complex, and the cause of injury is multiple.
Index ofThumb andOther Fingers Defect
(Fig.3.1)
Index ofThumb Defect
Now we described that as follows:
3.1 Design andChoice ofOperation Plan
Indications and contraindications for nger reconstruction are very important and should be the foundation of
preoperative assessment and design of the operation plan.
© Springer Nature Singapore Pte Ltd. 2023
J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_3
I degree defect: defect in the distal segment of thumb, it is
divided into I1 and I2 by the midline of the distal segment
of thumb.
II degree defect: defect in interphalangeal joint of thumb.
III degree defect: defect in the proximal segment of thumb.
IV degree defect: defect in metacarpophalangeal joint of
thumb.
V degree defect: defect in the rst metacarpus.
VI degree defect: defect in carpometacarpal joint of thumb.
81
82
ab
Fig. 3.1 Index of the thumb
and other ngers defect. (a)
Index of the thumb defect. (b)
Index of the other ngers
defect
3 Preoperative Treatment forFinger Reconstruction
Index ofOther Finger Defect
I degree defect: defect in distal segment.
II degree defect: defect in distal interphalangeal joint.
III degree defect: defect in middle segment.
Assessment ofBone andJoint
To judge if there is bone defect, fragment, osteomyelitis,
joint stiffness, ankylosis, and joint fusion according to X-ray
and joint range of motion.
IV degree defect: defect in proximal interphalangeal joint.
V degree defect: defect in proximal segment.
VI degree defect: defect in metacarpophalangeal joint.
VII degree defect: defect in metacarpus.
Assessment ofSkin Condition ofFinger Stump
To observe the appearance of nger stump and nd if there is
keloid, pigmentation, infection, rupture, bone exposure, skin
graft, transfer ap, xerosis, scar sticking to bone, etc.
Assessment ofNerve ofFinger Stump
To judge if there is a nerve defect, residual traumatic neuroma, and hyperesthesia according to pain sensation, temperature sensation, and tow-points discrimination.
3.1.3 Assessment ofVascular Condition
ofDonor andRecipient Site
It is very important to get a comprehensive understanding of
vascular condition of donor and recipient site for those toeto- hand reconstruction patients, especially donor site to complete preoperative plan design.
Observation andTouch
Normally, relatively large veins in the dorsum of the hand
and foot could be easily observed, and the existence of dorsalis pedis artery, posterior tibial artery, radial artery, and
ulnar artery could be felt by touch.
Assessment ofTendons
To judge if there is tendon defect, adhesion of tendon, and
the adhesion site according to the history of disease and surgery and examination of nger motion.
Portable Color Doppler Ultrasonography (Fig.3.2)
Portable color Doppler ultrasonography is non-invasive
equipment that is small in size and easy to be carried.
3.1 Design andChoice ofOperation Plan
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
a b
83
Fig. 3.2 CDFI location images. (a) Perforators can be identied by
color ultrasonography of cutaneous artery penetrating deep fascia into
subcutaneous area; (b) The complete anatomical morphology, (1) The
Doppler could be used to detect routine and type of rst
dorsal metatarsal artery. Generally speaking, strong sound of
Doppler means that the artery is large, strong, and supercial, obviously, what weak sound means is just on the
contrary. Of course, the judgment of sound is based on experience accumulation and actual anatomy.
Gilbert type I: when rst dorsal metatarsal artery is supercial, strong-intermediate sound could be continuously
detected in rst intermetatarsal space.
Gilbert type II: when rst dorsal metatarsal artery is
located on deep surface of the interossei, strong sound could
be detected at the site of dorsalis pedis artery and deep plantar artery, then turn to intermediate-weak, and turn to intermediate at toe web.
Gilbert type: when rst dorsal metatarsal artery is small or
even absent, strong sound could be detected at the site of dorsalis pedis artery and deep plantar artery, then turn to weak
even disappeared, and turned to intermediate at toe web.
According to literature reports, accuracy rate of portable
color Doppler ultrasonography is only 50–70% and is closely
related to operator’s clinical experience which means it could
only be reference for surgeons.
CT Angiography (CTA) (Fig.3.3)
CTA is enhanced CT scan technique combined with a thin
scan, large range, and fast scan technique that could display
peroneal artery; (2) Perforators; (3) The cutaneous artery; The yellow
arrow indicates measuring root diameter
details of blood vessels in all parts of body clearly which is
non-invasive and easily operated. CTA is important in vascular variation and diseases that are worth to be popularized
where the conditions are permitted.
CE-MRA (Fig.3.4)
CE-MRA can basically obtain the same effect as CTA, which
is more expensive but without radiation. Doctors could make
choices according to actual circumstances.
3.1.4 Operation Design
Operation design is very important since the purpose of nger reconstruction is to reconstruct ngers that is close to
the original ones in appearance and function. A reasonable
and mature operation design should have the following
features:
(a) To choose the right toe or part of the toe to reconstruct the
nger according to its degree of defect, the appearance
and function should be considered as also.
(b) The function and arch of donor foot should not be
affected. The protection of vessels, nerves, and tendons
should pay attention to when dorsal pedis ap is
needed.
84
3 Preoperative Treatment forFinger Reconstruction
a
b
d
c
Fig.3.3 A The CTA images. (a) A branch from the middle and upper
1/3 of the peroneal artery (the yellow arrow); (b) The plane and anatomical morphology of the perforators were shown (the yellow arrow);
(c) The design of two-end aps should be reasonable since
the circumference of the nger and toe is not matched
usually so as to avoid soft tissue defects and exposure
around the toe-to-hand site.
(d) To cut vessels, nerves, and tendons should be better long
than short as the principle.
(c) Projective technique demonstrated the perforators of the peroneal
artery (the yellow arrow); (d) Some percutaneous perforators cannot be
determined by CTA images alone
(e) Vascular pedicle should be covered with excellent
skin.
(f) Anatomic variation and various abnormal conditions
should be considered and the way to deal with should be
prepared, sometimes exible capacity is also needed to
complete the operation.
3.1 Design andChoice ofOperation Plan
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 3.4 CE-MRA
85
3.1.5 Indications andContraindications
Indications
The premise is that the patient must have the desire and
requirement for nger reconstruction and is aged from 3 to
60years old with the good general condition. After that the
followings should be considered:
(a) Thumb defect should be above degree I2.
(b) Defects happen on all ve ngers and the stumps are
non-function.
(c) Defects in the middle of the proximal phalangeal bone
of the other four ngers except thumb, or the residual
nger could not complete opponens function with
thumb.
(d) Defect in the middle of the proximal phalangeal bone of
index nger, middle nger, and ring nger, and the little
nger could not complete opponens function with
thumb.
(e) Single residual nger or two ngers without opponens
function.
(f) Congenital absence of nger that meets above
conditions.
(g) Those who have needs of occupation, beauty, and
communication.
Contraindications
(a) Local infection.
(b) Patients with systemic diseases who cannot tolerate the
operation.
(c) Patients with active tinea pedis or psoriasis.
(d) Severe burn and frostbite on foot and hand.
(e) Severe hematological disorders, such as hemophilia,
leukemia, etc.
(f) Vascular diseases in limb and foot, such as thrombus
vasculities, etc.
(g) Patients with serious mental or psychological disease
that is not under control.
(Note: Finger reconstruction should not be performed on
those who are without desire for reconstruction.)
3.1.6 Preoperative Preparation
Preparation ofSurgical Team
Surgeons should check patients’ general condition, degree of
injury, and associated supplementary examinations to clear
indications and contraindications before the operation to
make operation design according to the injury situation and
patients’ desire. All details of the operation such as the risks,
complications, responses, etc., should be communicated
with patients and their families, and then sign a detailed
informed consent. Good rest and excellent microsurgical
technique of surgical team are the basis of a successful
reconstruction. If the condition permits, the surgical team
may consist of multiple groups so that donor and recipient
sites could be operated at the same time which could reduce
operation time.
Preparation ofPatients
Patients and their families should totally understand the surgical methods and postoperative rehabilitation programs,
also be prepared for possible complications and unexpected
matters such as side injury, sequela, vascular crisis, failure of
the operation, second stage operation, etc. The majority of
patients need to stay in bed for 7–10days, so they should get
used to being in bed to practice diet and defecation before the
operation. Hands and feet cleaning and quitting smoking are
also necessary to reduce the danger of infection and vasospasm. The patients with other diseases such as malnutrition,
anemia, etc., should get into top physical shape which is
good for postoperative recovery.
86
3 Preoperative Treatment forFinger Reconstruction
Preparation ofOperation Room andAnesthesia
A spacious operating room that is enough for microscope
and multiple groups of surgeons for operation should be
arranged for nger reconstruction. Microsurgical equipment
should also be prepared.
An experienced anesthesiologist is also needed for safety
of operation since the long period of nger reconstruction.
Further Reading
Cheng GL, Replantation and reconstruction of nger. The second edi-
tion, Beijing, People’s Medical Publishing House, 2005
Pei GX, Microsurgical orthopaedics. Beijing, People’s Medical
Publishing House, 2016.
Lin J, Zheng HP, Xu YQ, Zhang TH.Special type of nger replantation.
Springer, 2018.
Commonly Used Instruments,
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Equipment, andMaterials forFinger
Reconstruction
4
Abstract
To repair and reconstruct the appearance and function of
a traumatic amputated limb is always the common aspiration of both doctors and patients. But absolutely the simple suture and bone xation cannot achieve our aim. It
came true with the development of microsurgery that
solved the problem of the vascular anastomosis to reconstruct circulation until the 1960S.
In early time, Carrell’s three stay sutures end-to-end
anastomosis or sleeve insertion is a major method for the
repair of vascular which is suitable for large blood vessels
and is very difcult for those blood vessels under 1.5mm.
The low recanalization rate and survival rate promote the
development of the microscope, microsurgery instruments, microsurgical suture material, new methods of
suture, anti-coagulation, etc.
Nylen and Hoimgrem rst performed inner ear surgery under microscope in 1921 which developed slowly
due to limited space. Barraquer and Pertt performed cornea suture under microscope in 1950 meant new suture
stage coming. Microsurgery entered a new stage of
development in the 1960s with the development of
microsurgical techniques. Jacobson and Suarez sutured
animal vessels whose diameters were from 1.6 mm to
3.2mm under 25 times microscope and the recanalization was 100% of what attached attention of surgeons.
After that Lee (1961), Gonzales (1962), and Abbott etal.
performed portocaval shunt, kidney transplant, and heart
transplant in animals successively. Malt successfully
replanted an amputated upper limb for a 12-year-old
child in 1962. Zhongwei Chen successfully replanted a
completely amputated forearm under the naked eye in
1963. Shuhua Wang and Jiaze Lu completed the rst
replantation of a rabbit ear in 1964 and successfully
replanted a completely amputated nger of a child in the
same year. Buncke and Schultz performed a successful
toe-to-thumb reconstruction for a monkey in 1965.
Dongyue Yang and Jianqiu Tang et al. were the rst to
perform second-toe-to-thumb reconstruction which was
a cooperation with Huashan hospital and Zhongshan hospital in Shanghai on February 13, 1966, and was the
beginning of a new era for thumb reconstruction in
China.
Keywords
Instruments · Equipments · Materials · Finger
reconstruction
4.1 Commonly Used Microsurgical
Instruments, Equipment,
andMaterials
4.1.1 Operating Microscope (Figs.4.1
and4.2)
History ofOperating Microscope
Microscope is an instrument that could produce an enlarged
image of an object by means of a physical method. It was
invented in the late sixteenth century and has been over
400years of history that has been an important instrument in
science research.
In 1876, Edvin Seamisch who was an ophthalmologist
made the rst wearable magniers for assistance in surgery
that were only two to eight times larger, compared with that
time the wearable magniers used now are 2–20 times larger.
In 1953, the rst operating microscope named OPMI 1
(Operating Microscope Number One) came out what was
© Springer Nature Singapore Pte Ltd. 2023
J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_4
87
88
4 Commonly Used Instruments, Equipment, andMaterials forFinger Reconstruction
Fig. 4.1 Surgical microscope
with the help of Doctor Hans Littmann and professor Horst
Wullstein. At the expo in Amsterdam, professor Horst
Wullstein introduces an operating microscope to the public
for the rst time. Since then, the operating microscope had
been expanded rapidly into other areas of microsurgery.
Although the rst operating microscope was designed for
middle ear surgery, it is still considered to be the ancestor of
universal microscope.
Advantages ofOperating Microscopes
(a) The application of electromagnetic brake provides a
exible movable joint for operating a microscope which
makes it more convenient for doctors to operate.
Fig. 4.2 Surgical microscope made in China
(b) Low angle double microscope can protect a doctor’s neck.
(c) Computer technology helps doctors set and preserve
working parameters better and also regulate the function
of operating a microscope better.
(d) APO achromatic lens could correct three primary lights
(red, yellow, and blue) at the same time, to solve the
color difference due to different refractive and magnication so as to present a perfect image.
Requirements forOperating Microscope
(a) Magnication is about 10 times, which is best between 6
and 40 times to meet different needs. When doubling
there is no need to refocus to make the image clear.
ab
4.1 Commonly Used Microsurgical Instruments, Equipment, andMaterials
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
89
(b) A long working distance to facilitate the operation
should be between 200mm and 400mm, usually about
275mm. If deeper operation is performed, the objective lens with a longer working distance can be
replaced.
(c) Light sources should meet requirements of high lumi-
nance and enough range which should better be a cold
light source to prevent tissue burns during a long period
of operation.
(d) The enlarged image should be a stereo-orthophoto image
which is convenient for accurate operation and two eyeglasses are required for observation from different
angles.
(e) Two pairs of double microscopes and a unied eld of
view are required for assistance’s corporation.
(f) Eyeglasses can be used to adjust the visibility and pupil-
lary distance to meet different needs.
(g) Photographic and video equipment is required.
(h) The microscope should be easily moved and equipped
with a manual, foot, or voice control device.
4.1.2 Operating Magnifying Glasses
Binocular Loupe (Fig.4.3b) utilizes an optical stereoscopic
convergence technique that focuses the Binocular line of
sight stereoscopic into a narrow cavity to produce a bright,
magnied 3D eld of vision which could provide a unique
stereoscopic depth image for examination and treatment.
There are three types of operating magnifying glasses that
are usually used in clinic.
(a) General operating magnifying glasses (Fig. 4.3a) A
magnifying lens is installed on a bracket through which
the surgeons could perform the operation, but this kind
of magnifying glass is seldom used in the clinic since its
occupation of large space, short working distance, low
magnifying power and inconvenience for use.
(b) Lens type of operating magnifying glasses Two rectan-
gular lenses with the same magnication power are
installed in front of the glasses usually used by the surgeon whose magnication power is generally no more
than two times and it can be also modied into the frontal band type for those who do not wear glasses.
(c) Telescope-type operating magnifying glasses It is com-
posed of a negative lens and a positive lens installed on
the spectacle frame of the forehead frame. The pupil distance can be adjusted by the crossbar of the glasses to
meet the need of different surgeons. Generally, the working distance is 240–350mm, and the magnication of
each pair is different which provides different options
for surgeons. It is helpful for the operation of all kinds of
tiny blood vessels and nerves suture and it has the advantages of being easy to carry and low price.
Fig. 4.3 (a) Surgical magnier. (b) Head loupe
Соседние файлы в папке @xirurgi_2025