REPLANTATION (Latin replantare again to put, replace) — operational engraftment of the body which is temporarily separated from an organism or its segment. The term «replantation» was offered at the beginning of 20 century by E. Hopfner and A. Karrel, and in Russia N. A. Bogoraz.
The greatest practical value has R. of extremities (fig. 1) and their segments: brushes, foot and fingers (see. Microsurgery ). Also R. of a scalp (fig. 2), an auricle, a nose, teeth, a penis, testicles, etc. are made. Replantation of a kidney, liver, lungs, heart and some other bodies hl, obr carry out. in experiments on animals.
R. became possible only after development of methods of a seam of blood vessels (see. Vascular seam ), and especially after implementation in a wedge. to the practician of an operative microscope, microsurgical tools, the microsurgical equipment and the thinnest suture material (see. Microsurgery ). For the first time in 1902 Mr. E. Ullmann and A. Karrel independently from each other, having applied a vascular seam, kidneys at a dog carried out R. The first R. extremities using a vascular seam in an experiment on a dog was made in 1907 by Hepfner.
In 1962 R. A. Malt for the first time successfully replantirovat the right hand of the boy of 12 years, after traumatic amputation at the level of an upper third of a shoulder. In 1963 Mr. Chen Chung Twist (Ch’en Chung Wei) with sotr. carried out successful R. of a brush at the worker. The first successful R. of a thumb of a brush was executed in 1965 Mr. Komats and Tamai (S. Komatsu, S. Tarnai). Now R. of fingers, brushes, extremities and other amputated bodies carry out in the centers of microsurgery in our country and abroad.
The big contribution to development of a problem P. of an extremity in an experiment and preparation for its implementation in a wedge, practice was brought by domestic researchers A. G. Lapchinsky, N. P. Petrova, A. D. Hristich, G. S. Lipovetsky, I. D. Kirpatovsky, T. M. Oksman, L. M. Saburova, V. A. Bukov, Yu. V. Novikov, etc.
R. in the theoretical relation is based first of all on results of studying of viability of fabrics and bodies, edges depends on an anatomic structure of body, extent of its damage, duration of a thermal and Cold anoxia, a way of preservation. R.'s possibility of the separated body having big weight (e.g., extremities), depends as well on the general condition of an organism, a cut is defined by the size of blood loss, weight of shock, existence of the combined damages, water and electrolytic disturbances, and also associated diseases (the diabetes mellitus, obliterating endarternit, atherosclerosis, etc.).
Cells of a head and spinal cord, peripheral nerves extremely quickly react to a thermal anoxia whereas skin, hypodermic cellulose, sinews and bones transfer it within several hours and even days. According to experimental data duration of a thermal anoxia of internals shall not exceed 30 — 90 min. So, it is proved that the 30-minute thermal anoxia leads to destruction of tissue of lung, and for a small bowel the marginal term of a thermal anoxia, by data morfol. researches, 60 min. then arise inside - and extracellular changes in neuroplexes are. Prolongation of an anoxia of bodies is possible only at a hypothermia (t°4 °), perfusions of the separated body and other actions (see. Hypothermia artificial , Oxygenators , Perfusion ).
Adequate recovery of function of heart at a temperature of 37 ° is possible at an anoxia within 30 min. At preservation of heart complex means, according to Cooper (D. To. Cooper), it is possible to increase this term till 24 o'clock. The cardiopulmonary complex manages to be replantirovat in 1 hour after the termination in it of blood circulation, perfusing it oxygenic blood.
Admissible terms of a thermal anoxia for a kidney of 30 — 90 min., but regarding cases the canalicular necrosis can arise in 15 — 30 min. The hypothermia of a kidney in this period is of great importance for the subsequent its replantation since at decrease in temperature to 10 ° the need of fabric for oxygen decreases twice and remains at the level of 5% initial during the cooling to 5 °.
Definition of viability of the extremity separated from an organism presents great difficulties so far. According to M. P. Vilyansky and And. V. Vedeneyeva, the thermal anoxia of an extremity during term to 12 hours is not a contraindication to recovery of the main blood-groove if viability of muscles according to an electromyography does not raise doubts.
The changes occurring in an organism at R. of an extremity are diverse and develop not only in replantirovanny body, but also in other bodies and systems. Set of these changes makes the syndrome of replantation of an extremity including disturbances of the central hemodynamics, functions of kidneys and a liver, biochemical shifts and characteristic changes in a replantirovanny extremity — denervation, hypostasis, dystrophic changes.
The complex of influences is the cornerstone of a pathogeny of a syndrome of replantation, from to-rykh main are: an injury (see) and blood loss (see), and also multiple small hemorrhages and plazmopoterya in the postoperative period, toxicosis as a result of receipt in a blood stream after R. of toxins, products of the perverted exchange and destruction of ischemic fabrics (see. Traumatic toxicosis, Shock).
Originally in a wedge, a picture signs of traumatic shock, later — the phenomena of ischemic toxicosis and a plaz-mopotera prevail more often, to-rye can reach varying severity. Quite often after R. of an extremity heavy changes of function of a liver and kidneys are observed, to-rye regard as manifestations of a hepato-renal syndrome (see). These disturbances can be so considerable that there is a requirement in special to lay down. actions.
Major importance at R. is attached to the level of amputation: the distalny the level of amputation, is less than the weight of the fabrics and muscles deprived of blood circulation the danger of developing of toxicosis is less, and at R. of a finger toxicosis is not noted at all.
Allocate «макрореплантацню» at traumatic amputation of an extremity proksimalny radiocarpal and talocrural joints and «microreplantation» at amputation of an extremity distalny these joints. Besides, refer operational engraftment at amputation of an auricle, penis, scalp to a mikroreplanta-tion.
At development of indications to macroreplantation paramount value has viability of an extremity because of limited time of an anoxia (no more than 6 hours of an admissible thermal anoxia). It is explained by threat of development of a serious general condition of the patient caused by extensiveness of an injury and developing of intoxication in the postoperative period. Toxicosis at R. is most expressed of the lower extremities amputated at the level of a hip, and upper extremities — at the level of a shoulder.
At microreplantation the condition of patients practically never fills with misgivings, but recovery of blood supply requires use of the microsurgical equipment (see. Microsurgery ). At microreplantation duration of a thermal anoxia can be St. 6 hours that is connected with absence or the minimum quantity of muscular tissue (e.g., in a finger). In all cases of amputation of body of a pla of its segment cold preservation at t is necessary ° 4 ° in special plastic bags with ice. Amputation of a thumb of a brush is the most frequent indication for R. in connection with the big importance of this finger for function of a brush. At amputation of the II—V fingers which do not have paramount value for function of a brush, operation P. can be discussed with the patient. The profession of the victim has important value. At development of indications to R. and definition of viability of the separated body it is necessary to consider a look amputations (see) and damage rate of fabrics.
Technology of replantation
Replantation assumes a complete recovery of anatomic and functional integrity of the separated body or its segment. On preparatory ethane make processing of a stump, excise all impractical fabrics, and also provide perfusion of the separated body. At the subsequent stage (for extremities and their segments) shortening and removal of freely lying bone fragments, an osteosynthesis (see), a seam of sinews are necessary (see. Tendinous seam ). The vascular stage — the main at any R. — consists in anastamosing of arteries, veins (see. Vascular seam ) and nerves (see. Nervous seam ).
the Most frequent and serious complication after R. — thrombosis of vessels, are more often than veins, to-ry it is possible to suspect on change of temperature and color of replantirovanny body, lack of a pulsation of peripheral arteries. At arterial to fibrinferment (see) replantirovanny body pale, it is not filled with blood, there is no venous drawing. At phlebothrombosis (see) cyanosis, puffiness and tension of fabrics is noted. At fibrinferment of vessels in the field of an anastomosis repeated operation is shown — thrombectomy (see) or a resection of an anastomosis with the subsequent autoplasty of a vessel.
After macroreplantation of an extremity the main attention shall be paid to performing disintoxication therapy, correction of protein and water and electrolytic metabolism, careful control of function of a liver and kidneys. If necessary it is necessary to apply a hemodialysis (see) and hemosorption (see. Hemosorption ). Also sessions of hyperbaric oxygenation are shown (see). At the state menacing for life and increase of intoxication the emergency removal of replantirovanny body is shown.
zagisit the Forecast from timely hospitalization of the victim in specialized department, duration of an anoxia and a way of preservation, a type of amputation. Reduction of term of an anoxia, especially thermal, at R. of an extremity significantly affects an outcome R. Chem well a time term before operation and the earlier the hypothermia of the amputated body is begun, the it is more than chances of a favorable outcome. The result of replantation of any body or its segment at guillotine amputations when there is a smooth section is optimum and damages of all anatomical structures to a zone of amputation are minimum. The river of fingers or a brush at guillotine amputations yields up to 95% of favorable results on condition of R.'s performance in the specialized center. At crush, a separation, scalping in a zone of amputation — R.'s outcome less favorable.
Replantation of teeth
Replantation of teeth — operational engraftment of the extracted tooth in the same tooth socket. Now apply also transplantation and implantation of teeth, and also transplantation of dental germs. However these ways are less reliable because of manifestation of reaction of a tissue incompatibility (see Incompatibility immunological). The first attempts of development of a technique of R. of teeth belong to the first half of 19 century. Gradually this operation was widely adopted enough as one of types of bone plastics (see), but frequent complications (an inflammation around the replaced tooth) forced many doctors to refuse it. Implementation in medical practice of antibiotics opened new perspectives for R. of teeth.
Experimentally - morphological researches demonstrate that R.'s success of teeth directly depends on safety of a periodontium on a root of the replaced tooth. At its good safety between it and a bone alveolus the fibrous union due to regeneration of bunches of collagenic fibers is formed. At partial preservation of a periodontium between the replaced tooth and a bone of a tooth socket the fibrous union is also formed. At total absence of a periodontium accretion occurs between cement of a root and a bone of a tooth socket, but further there is a resorption of cement of a root and death of a replantat. The favorable result of operation is impossible without good blood circulation in surrounding fabrics. Replantirovanny teeth strongly become stronger in alveoluses in 3 — 4 weeks after operation and can be used as fixed dentures, basic at production.
Indications to R. of teeth is the impossibility of preservation of tooth by conservative or surgical methods of treatment in connection with hron. periodontitis or its aggravation when channels of roots, especially big molars, are impassable and it is close prilezhat to Highmore's (maxillary, T.) to a bosom or channel of a mandible; dislocation of tooth or a change of its root at a top; an arrangement of a fang in an okolokornevy cyst of the small sizes, in big or small molars, and also at an epulisa, coming from pe ~ a riodonta of tooth; anomalies of eruption (allotopia). Thus replantation of tooth is possible when its removal can be carried out without disturbance of walls of a tooth socket and at safety of a crown of tooth.
Contraindications to R. of teeth are considerable destructions of bone walls of a tooth socket, from - scrap of fangs during its removal, sharp disturbances of exchange processes in an organism (at a diabetes mellitus, a hypovitaminosis, etc.).
Before R. visually define rate of decay of a crown of tooth, safety of a mucous membrane of a gingiva, and according to a X-ray analysis — the relation of tooth to the next educations. Define also need of an immobilization and its character. If the immobilization is supposed double parallel aluminum tires, they are produced before River.
Rubles will see off with observance of rules of an asepsis, under an infiltration or conduction anesthesia (see. Anesthesia local ). The circular ligament of tooth accurately, without gaps is otslaivat and extract the tooth which is subject to replantation, trying to injure walls of a tooth socket minimum. The extracted tooth is placed in the isotonic solution of sodium chloride containing streptomycin. Delete with an acute spoon granulyatsionny fabric from a tooth socket, tampon an alveolus a gauze napkin. Then process replantat: resect tops of roots for what, holding tooth nippers, they are sawn off a separation disk (fig. 3, a), process and seal up carious cavities. Broaden channels of fangs (fig. 3, b), delete from them disintegration and seal up a fosfattsement, (fig. 3, c), and the part expanded in the form of a cone amalgam (at children only a fosfattsement). The neck of tooth is cleared of the remains of a periodontium and tooth deposits. Tooth after processing is placed in isotonic solution of sodium chloride with antibiotics. After removal from a tooth socket of a gauze napkin the alveolus is washed out isotonic solution of sodium chloride and filled up with powder of streptomycin. The tooth prepared for R. is placed in a tooth socket and fix it the aluminum tire to the next teeth for 3 — 4 weeks (fig. 4). Fixing by the tire from quick-hardening plastic is possible.
At acute periodontitis (see) or its aggravation R. carry out in two steps. At the first stage extract tooth and place in isotonic solution of sodium chloride with antibiotics where it is stored to R. Alveolu of the extracted tooth fill with a gauze tampon. In 6 — 8 days after subsiding of the inflammatory phenomena make the River. At R. of multi-rooted teeth they are strongly strengthened in tooth holes, sometimes without carrying out an immobilization. When recovery of a crown of tooth is necessary, it can be made before change of tooth.
See also Transplaptation (bodies and fabrics) .
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G. A. Stepanov; V. I. Zausayev (ostomies).