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Digit Replantation / Upper Extremity Reconstruction

 - 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.   

Major limb replantation.     

Replantation of the Digits and Hands from the Orthopaedic Care Textbook 

The Preoperative Preservation of Amputated Digits: An Assessment of Proposed Methods.