两例异体移植手功能康复早期报告

摘要

目的报告2例异体移植手早期功能康复结果。方法2例心理和一般情况良好的右手外伤性缺如患者，通过组织配型后接受2例与其相匹配、无传染病脑死亡供者的异体手，移植方法基本同断肢再植。术后密切观察生命体征、移植手血液循环和监测免疫排斥反应。术后进行心理治疗并在康复医师指导下进行功能锻炼。结果Tinel征检查显示神经生长速度较快。术后4个月，移植手可以持物，痛、温觉测试和Tinel征检查显示，神经已生长至拇指、示指和小指末节及中指、环指远侧指间关节。术后5个月，例1移植手拇指、小指有外展动作。术后6个月，例1拇指、小指外展动作增强且可抗阻力，能写字；例2移植手拇指、小指亦有外展动作。术后7个月，两患者尺、桡骨愈合良好，去除内固定物并同时行肌腱和神经松解。术后8个月，移植手功能进一步加强，可以打羽毛球、拍篮球。术后9个月可以切菜。术后10个月，例1手指运动功能恢复等级为良，正中神经优、尺神经良；例2手指运动功能恢复等级为良，正中神经与尺神经均为可。结论移植手近期功能与自体断肢再植相似。为了提高异体移植手的功能，术前应严格筛选病例，受、供体组织配型要匹配，并制定合理的手术方案；术中操作精确、熟练；术后合理应用免疫抑制剂，同时配合实施良好的康复措施，对促进异体移植手的功能康复具有重要意义。%Objective To report the results of funtional recovery of hand in two patients undergone human hand allograft. Methods Two male recipients, with traumatic right wrist amputation for 2 years, were matched respectively with two donors died of cerebral injury. The transplantation procedure was similar to that of autologous replantation of severed limb. After surgery the patients were given wide spectrum antibiotics, anticoagulations, antispasm agents, and immunosuppressants. Clinical observations included vital signs and circulation of the hands. Immune status was monitored and skin biopsy was done to exclude rejection. The patients were also given psychotherapy and hand rehabilitation. Results Rapid regeneration of the nerves were determined by Tinel s sign. At 4 months after surgery the function of grafted hands recovered well, which could already hold a drinking cup. The nerves had grown to the end of fingers and electromyograph showed regenerative action potentials of thenar muscles. At 5 months the thumb and small finger could abduct in case 1. At 6 months the thumb and small finger could abduct against resistance in case 1, and the thumb and small finger could also abduct in case 2. At 7 months the bone united and the fixation were removed, meanwhile the tendons and nerves were released. At 8 months the hand function get further improved. At 10 months the two grafted hands were graded good by total active motion evaluation, and in case 1 the median and ulnar nerves recovered excellently and well respectively; and in case 2 both of the median and ulnar nerves recovered fairly. Conclusion The early function recovery was similar to that seen in autologous replantation. In order to have good function of transplanted hand proper, patients should be carefully chosen. Important key of success are: ideal histocompatability, the use of immunosuppressants and thorough planning of atraumatic operative procedure, as well as the implementing of rehabilitation.