- 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.
- 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;
- reference
- The use of Y-shaped interposition vein grafts in multiple digit replantations.
- Repair Nerves
- reference:
- Digital sensibility following replantation.
- 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;
- Prevention of Anastomotic Thrombosis by Botulinum Toxin B After Acute Injury in a Rat Model
- 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.
- Major limb replantation.
- flexor tendon adhesions:
- reference:
- Results of flexor tendon tenolysis after replantation in the hand.
- cold intolerance:
- reference:
- 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.
Twenty years experience of limb replantation - a review of 293 upper extremity replants.
Replantation of the Digits and Hands from the Orthopaedic Care Textbook
The Preoperative Preservation of Amputated Digits: An Assessment of Proposed Methods.