Replantation

DEFINITION

 REPLANTATION : reattachment of a part that has been completely

amputated —no connection exists between the severed part and the
patient

 REVASCULARIZATION : repair of a part that has been incompletely

amputated —some of the soft tissue (e.g., skin, nerves, or tendons) is intact
INDICATION

 Thumb
 Multiple digits
 Partial hand (amputation through the palm)
 Almost any part in a child
 Wrist or forearm
 Elbow and above elbow (sharply amputated or moderately avulsed)
 Individual digit distal to the flexor digitorum superficialis (FDS) tendon
CONTRAINDICATION

 Severely crushed or mangled parts

 Amputations at multiple levels
 Amputations in patients with other serious injuries or diseases
 Amputations in patients with severely arteriosclerotic vessels
 Amputations with prolonged warm ischemia time
 Amputations in mentally unstable patients
 Individual finger amputations in an adult at a level proximal to the FDS
insertion (particularly in the index or small fingers)
RING AVULSION CLASSIFICATION

 CLASS I : Circulation is adequate. Standard bone and soft tissue treatment

is sufficient.
 CLASS II : Circulation is inadequate. Vessel repair preserves viability
 CLASS III : Complete degloving or complete amputation.
INSTRUMENT
 Surgical loupes or telescopes with 3.5× to 4.5× magnification
 Operating microscope, preferably a diploscope with magnification at least
to 20×
 Fine spring-loaded (nonlocking handles) needle holders and scissors
 Jeweler’s forceps, small-tipped tying forceps,
 a microtipped dilator (lacrimal duct dilator), and a microirrigator
 (30-gauge needle attached to a plastic syringe)
 Two clips mounted on a sliding bar
 Small silver vascular clips (hemoclips).
 Small-tipped bipolar cautery
 Small piece of blue or yellow rubber balloon or plastic as background
material
NEEDLE AND SUTURE SIZE
PREPARATION FOR TRANSPORT
(PRESERVATION)
 Wrapping the part in gauze moistened with lactated Ringer’s or saline
solution and placing the bundle in a specimen container or plastic bag,
which is then placed on ice
 Immersing the part in one of these solutions in a plastic bag or specimen
container and placing the bag or container on ice
TIME LIMIT

•Proximal To Carpus
warm ischemia time < 6 hours
cold ischemia time < 10-12 hours

•Distal To Carpus (Digit)

warm ischemia time < 12 hours
cold ischemia time < 24 hour
 INCISION

midlateral incision are preferred for

an amputated digit and stump
Incision are made slightly towards
the dorsal side so that both the
dorsal and olar skin can be
reflected to locate the arteries and
vein with ease
STEP
TO DO REPLANT
1. Locate and tag the vessels and nerves.
2. Débride.
3. Shorten and fix the bone.
4. Repair the extensor tendons.
5. Repair the flexor tendons.
6. Anastomose the arteries.
7. Repair the nerves.
8. Anastomose the veins.
9. Obtain skin coverage.
BONE STABILIZATION

 One or two longitudinal intramedullary Kirschner wires

 A longitudinal intramedullary Kirschner wire plus a short oblique Kirschner
wire to prevent rotation,
 Crossed Kirschner wires
 Intraosseous wiring
 An intramedullary screw or peg
 A small plate with screws
TENDON REPAIR

 EXTENSOR : usually, two horizontal mattress sutures of 4-0 polyester are

sufficient
In some severe avulsion injuries, no extensor tendons are
available for repair, IP joint arthrodesis or extensor tendon
grafting as secondary procedures is necessary.
 FLEXOR : Tajima suture method, Kessler, modified Kessler, bunnel
ARTERIAL REPAIR

 DO NOT ATTEMPT TO REPAIR UNTIL SPURTING BLOOD FLOW OCCURS FROM

PROXIMAL VESSEL
 Flush the distal vessel with ringer lactat solution
 Damaged microvesel must be sharply incised back to normal intima
 Beware of : “red line sign” (damage to the underlying digital artery)
“ribbon sign” (too much stretched, it curls like a ribbon)
 ARTERIAL REPAIR
 STEP :
1. relief of vascular tension or compression
2. proximal resection to healthy vessel walls
3. warming of the operating room and patient
4. adequate hydration of the patient (crystalloid, blood, or both, when indicated)
5. elevation of the patient’s blood pressure
6. irrigation of the proximal vessel with warm lactated Ringer’s solution
7. external application or gentle intraluminal flushing with papaverine solution (1 : 20
dilution)
8. Check metabolic problem that could incite vasospasm (e.g., acidosis)
9. Do not inflate torniquet
 VEIN REPAIR
 How to decrease blood loss?
 Repair veins before arteries vs usage of tourniquet
 Adequate venous repair might be achieved by :
 repair of the volar veins
 anastomosis of one distal digital artery to a proximal vein
 removal of the nail plate and subsequent scraping of the raw nail matrix with a cotton-
bud every 1-2 hours and heparin-soaked pledget applied afterward to foster
continuous venous oozing
 transverse stab incision on the periungual area of the tip of the digit with the application
of heparin to maintain external bleeding
 use of medical-grade leeches
 periodic digital massage of the replanted fingertip
NERVE REPAIR

 Primary nerve grafts are performed when end-to-end repair is not possible
 The medial antebrachial cutaneous nerve is ideal as a donor for digital
nerve grafting
 No statistical difference in nerve recovery in our replants with secondary or
primary repair
 Peripheral nerves are repaired with 8-0 to 10-0 monofilament nylon by
epineurial repair
POSTOPERATIVE CARE

 Postoperative care may be categorized into three segments:

(1) routine precautions
(2) procedures for difficult replantation
(3) reversal of a failing replant.
 1. ROUTINE PRECAUTIONS

 Elevated position
 Antibiotics for 1 week
 Avoid smoke and caffein
 Bed rest 2 to 3 days
 Change dressing 2 weeks post operative
 Controversial : Anticoagulant
 ANTICOAGULANT

 CLEAN CUT
 Heparin is not generally indicated
 Choice of drugs : aspirin (325 mg/day)
Dipyridamole (50 mg three times per day)
dextran 40 (20 mL/hr)
chlorpromazine (Thorazine; 25 mg three times per day).
 CRUSH OR AVULSION
 Intravenous heparin, 1000 U/hour, for 5 to 7 days
 What to evaluate?

 Color
 Pulp turgor
 Capillary refill
 Warmth (Skin temperature) {poor pefusion
<30oC}

■ Transcutaneus Oxygen Measurement

■ Laser Dopler Flowmetry
■ Fluorescein Pefusion
 2. PROCEDURES FOR DIFFICULT
REPLANTATION
 Heparin intravenous
 Adequate nerve block (for vasodilation)
 Bupivacaine 5 mL every 6 or 8 hours (continuous regional block)
 Brachial Plexus Catheter
3. REFERSAL OF FAILING REPLANT
MAJOR LIMB REPLANTATION

 AROUND ELBOW TIME LIMIT < 12 HOURS

 VENTRICULOPERITONEAL SHUNT for rapid arterial inflow if duration from
amputation > 4 to 6 hours
 SUNDT : 3-4 mm vessel
 LUDENZ : 2.5-3.5 mm vessel
 ARTERIAL BEFORE VEIN
 EXTENSIVE FASCIOTOMIES (beware of myonecrosis, provide adequate
decompression of the restored vessel)
 Evaluate soft tissue condition within 48 to 72 hours
 Do not use anticoagulants
What to expect?

 Clean cut better than crush injury/avulsion

 No man’s land usually not better than it distal/proximal
 Worst survival rate : 1st and 7th decade of lyfe
 Best survival rate : 2nd decade
 Cold intolerance