Controlled Clinical Study Of Surgical Flaps Treatment Effect On The Venous Congestion After Digital Replantation

Objective: When the finger appears vascular crisis after digital replantation, especially the venous congestion, it is difficult to treat and the necrosis rate of replanted finger is more higher. The purpose of the study is to analysis the clinical efficacy in application of two kind of surgical flap to relive venous congestion after digital replantation and to select a normative surgical approach to be used in the clinic.Methods: Since July 2013 to December 2014, the 28 fingers in 28 patients which appeared venous congestion after digital replantation were seen as research subjects. The cases after replantation who suffered the venous congestion and conservative treatment was invalid in 3 ~ 72 h, were included in the group and divided into two groups, each group of 14 patients. The cases were informed consent and were performed an operation by the same group of doctors and assistants professionally trained. In the first group, dorsal proximal pedicle flap of adjacent fingers was arised beyond extensor aponeurosis and translocated to the dorsal area of the replanted finger. The length of the pedicle flap was about 4.0cm to 4.5cm,and the width about 1.2cm to 1.5cm.After resection of dorsal vein thrombosis and inflammatory edema skin edge segment, the veins of proximal pedicle flap were anastomosed with that of replanted finger.Full- thickness skin was grafted to the donor site. After surgery,the digit was treated by anti-inflammatory, antispasmodic and anticoagulant. When the replanted finger was survival,the adjacent pedicle of flap was divided after four weeks for functional exercise;The second group, the free venous flap was havested in the forearm parts or dorsal area of the finger which included two parallel veins. The two veins were distributed parallel to the longitudinal axis in the free venous flap. The free venous flap was embedded defect area replanted finger and anastomosed. The area of the free venous flap was 1.2*1.5cm to 1.5*2.0cm and the free flap was not invert. The distal end of one vein was anastomosed with the dorsal vein stump of the replanted finger and after another vein proximal ligation, non-dominant side of the distal artery anastomosed with the vein stump. The donor sites were sutured directly. During the operation, operating time was recorded respectively in two groups(involved debridement,flap havested, deal with the donor and vascular anastomosis). Postoperative follow-up, the healing condition was observed in replanted fingers, including flap color, plumpness, tenderness,donor site and scar. According to the upper limb partial function evaluation standard issued by Hand Surgery Society of Chinese Medical Association and Michigan Hand Questionnaire(MHQ),two groups were comparatively analyzed.Results:1 The operating time of two groups was comparatively analyzed: the mean operating time of anastomosing dorsal vein of cross-finger flap was about 64±4.8 min, while the free venous flap was 82±3.6 min. There was significant difference between two groups(P<0.05).2 The survival situation of two groups was comparatively analyzed: the survival cases of anastomosing dorsal vein of cross-finger flap were 11 cases, healing under scab cases were 2 cases, partial necrosis case was 1 case. The survival cases of the free venous flap were 7 cases, healing under scab cases were 5 cases, partial necrosis cases were 2 case.The cases of partial necrosis were survival by skin grafting or union local transfer flap. Success rate of operation of both groups was compared. There was significant difference between two groups(P<0.05).3 The clinical effects were compared with two groups.The follow-up period ranged from 2 to 10 months,mean 6.7 months. According to the upper limb partial function evaluation standard issued by Hand Surgery Society of Chinese Medical Association and Michigan Hand Questionnaire(MHQS),two groups were comparatively analyzed.The group of anastomosing dorsal vein of cross-finger flap, sensory tests 10 cases got excellent result, 3 case good, 1 case poor; TAM 11 cases got excellent result, 3 cases good; with tenderness 1 case, without 13 cases; the situation of the donor healing 12 cases got excellent result, 2 cases good. The group of free venous flap, sensory tests 7 cases got excellent result, 5 case good, 2 cases poor; TAM 10 cases got excellent result, 4 cases good; with tenderness 3 cases, without 11 cases; the situation of the donor healing 12 cases got excellent result, 2 cases good. There was significant difference between two groups(P<0.05).Conclusion:1 The transfer of cross-finger dorsal flap can reflow the vein of the replanted finger and cover the wound with healthy skin and is more simple, effective. However, the second surgery is needed and slight functional impairments left.2 The free venous flap has a good clinical effect, but it is extremely necessary to have a higher microsurgical technique and necrosis rate of the flap is higher. There are different degrees of flap retraction and poor quality after flap survival. The free venous flap can be used in special cases.3 When fingers appeare venous congestion after digital replantation, the transfer of cross-finger dorsal flap is the most appropriate choice.