- See:
- Amputation of the Finger and Hand:
- Pharmocological Agents in Vascular Surgery:
- Second Toe Transfer:
- Thumb Defects:
- Indications for Replantation:
- Thumb amputation
- Multiple digit amputations
- Metacarpal amputation
- Almost any body part in a child
- Wrist or forearm amputation
- Individual digit distal to FDS insertion (see Zone I)
- replantation at level distal to insertion of FDS often results in satisfactory function;
- avgerage ROM at PIP joint is 82 deg, & 2-point discrimination avg 11.7 mm in adults (9.2 mm in children).
- cold intolerance subsides after approximately 2 years.
- references:
Digital replantation at the level of the distal interphalangeal joint and the distal phalanx.
Digital replantation distal to the proximal interphalangeal joint.
The Use of Arteriovenous Anastomosis for Replantation of the Distal Phalanx of the Fingers.
- ring avulsion injuries:
- Urbaniak classification:
- class I: circulation adequate: requires standard bone and soft tissue treatment;
- class II: circulation inadequate: requires vessel repai;
- class III:
- complete degloving injury or complete amputation;
- w/ concomitant proximal phalangeal frx or PIP joint injury, consider amputation;
- complete amputations proximal to the FDS tendon insertion should be treated w/ amputation;
- references:
- Microvascular management of ring avulsion injuries. JR Urbaniak, JP Evans, DS Bright. J. Hand Surg. Vol 6. 1981. p 25-30.
- Analysis of prognostic factors in ring avulsion injuries.
- Results of ray resection and amputation for ring avulsion injuries at the proximal interphalangeal joint.
- Contra-indications:
- severely crushed or mangled parts
- amputations at multiple levels;
- amputations in patients with other serious injuries or diseases;
- arteriosclerotic vessels
- mentally unstable patients
- distal amputations: (see: finger tip injuries:)
- amputations distal to the DIP joint are difficult to replant since the digital artery begins to branch and because the dorsal veins are hard to find;
- w/ distal amputation strongly consider amputation as a treatment alternative;
- prolonged warm ischemia (see reperfusion injury)
- > 6 hrs for proximal replantations (wrist)
- > 12 hrs for digits (some say 6 hrs warm ischemia, and 24-30 hrs ischemia time for digital replantation);
- individual finger in adult proximal to the FDS insertion (male pts)
- may consider proximal replant in children or females;
- single digit replantation proximal to FDS insertion produces a digit with significant functional impairment.
- avg PIP joint ROM in these digits is only 35 degrees, although cold intolerance & sensation are comparable to more distally amputated group;
- reference: The bioenergetics of preservation of limbs before replantation. The rationale for intermediate hypothermia.
- Surgical Technique: (in sequence)
- Preoperative Considerations:
- ensure that the digit is transported properly;
- reference: The bioenergetics of preservation of limbs before replantation. The rationale for intermediate hypothermia.
- Bilateral Midlateral Incisions:
- isolate vessels and nerves
- debride
- Shorten and Fix Bone (K wires or screws)
- references:
Skeletal fixation in digital replantation. Use of the "H" plate.
- Repair the Extensor Tendons
- Repair the Flexor Tendons
- in the case of a hand replantation the flexor and extensor tendons are repaired only after arterial and vensous flow has been established;
- Anastomose Arteries;
- w/ digit replantation, attempt to anastomose both arteries;
- w/ hand or forearm replantations, consider use of arterial shunt;
- before the vascular anastomosis give systemic heparin;
- references:
- The use of Y-shaped interposition vein grafts in multiple digit replantations.
- Repair Nerves
- reference:
- Digital sensibility following replantation. R. Gelberman et al. J. Hand. Surg. Vol 3. 1978. p 313-319.
- Anastomose Veins (2 for each artery, or 3 veins minimum);
- veins are never repaired before arteries, especially in hand or forearm replants, since reperfusion toxins will be re-circulated into the body;
- Skin coverage;
- Post Op:
- pharmocological agents in vascular surgery:
- temperature probe:
- motion of digits:
- significantly affected by overall injury sustained by the digit;
- motion of PIP joint accounts for 85 % of arc of finger motion;
- Complications:
-
failing replant:
- inspect and loosen dressing
- change hand position
- stellate block (spasm)
-
heparin bolus (3000 to 5000 units)
- if no improvement in 4-6 hours, return to the OR
-
infections:
- more common in upper extremity replantations which develops myonecrosis;
- references:
- Twenty years experience of limb replantation: Review of 293 upper extremity replants. J. Hand Surg. Vol 7-A. 1982. p 549-556.
- Major limb replantation. WA Morrison and BM O'Brien. Orthop. Clin. North Am. Vol 8. 1977. p 343-348.
-
flexor tendon adhesions:
- references:
-
Results of flexor tendon tenolysis after replantation in the hand.
-
cold intolerance:
- references:
-
Quantitative analysis of cold stress performance after digital replantation.
Longitudinal epiphyseal growth after replantation and transplantation in children.
The results of replantation after amputation of a single finger.
Skeletal fixation in digital replantation. Use of the "H" plate.
Results after replantation and revascularization in the upper extremity in children.
Above elbow limb replantation: Functional results. MB Wood. J. Hand Surgery. Vol 11-A. 1986. p 682-687.
Twenty years experience of limb replantation: Review of 293 upper extremity replants. S. Tamai. J. Hand Surg. Vol 7-A. 1982. p 549-556.
Major limb replantation. WA Morrison and BM O'Brien. Orthop. Clin. North Am. Vol 8. 1977. p 343-348.
Replantation of the Digits and Hands from the Orthopaedic Care Textbook
The Preoperative Preservation of Amputated Digits: An Assessment of Proposed Methods.
