Replantation

Question 1

What are the indications to reimplantaiton?

Answer 1

Thumb
multiple digits
almost all parts for children 
wrist to forearm
elbow and above elbow
individual digits distal to insertion of FDS

Question 2

What are the contraindications to reimplantation?

Answer 2

SINGLE DIGIT PROXIMAL TO FDS INSERTION -ZONE II- poor results due to loss of pipj motion due to flexor sheath adhesion
Mangled part- difficulty healing, infection->poor oc
multiple levels
other serious medical conditions
prolonged ischaemic time
self inflicted wounds
mentally unstable pt

Question 3

How is the amputated tissue transported

Answer 3

Keep moist in gauze with lactate ringers solution

place in sealed plastic bag then ice at 4oC

Question 4

What is the time to reimplantation

Proximal to carpus?

Answer 4

Warm ischaemic time 12 hours

Question 5

What is the time to reimplantation

distal to carpus?

Answer 5

warm ischaemic time <24 hours

Question 6

what is the sequence of structures you reimplant?

Answer 6

BEFANVS Be famous in funny accent!!

Bone 
Extensor tendons
Flexor tendons
Arteries
Nerves
Veins
Skin

Question 7

What order are fingers reimplanated?

Answer 7

Thumb
Long
Ring
Small
Index

Question 8

For multiple amputations what sequence is most effective?

Answer 8

Structure by structure

Question 9

For multiple amputations what sequence takes the longest?

Answer 9

Digit by digit

Question 10

What would your post care be?

Answer 10

Keep pt in warm room 80oF
Avoid caffeine, chocolate and nicotine

Implant- pulse oximetry 2 degrees within the hour post op or a temp below 30oC

Anticoagulant- adequate hydration
meds- LMWH

Question 11

How do you tx arterial insufficiency?

Answer 11

Restrict bandages
place extremity in dependent position
? heparinisation
Stellate ganglion block
early surgical exploration if non work
thrombosis secondary to vasospam is most common cause of early reimplant failure

Question 12

How do you tx venous insufficiency?

Answer 12

elevate extremity

Leech application- release Hirudin - anticoagulant or heparin soaked pledgets

Question 13

What are the complications of reimplanation?

Answer 13

Infection
cold intolerance
stiffness
myoglobinuria- muscle necrosis in larger implants-> renal implants and fatal
reperfusion injury- thought to be sue to mechanism of ischaemic induced hypoxanthine to xanthine- allopurinol best adjunct

Question 14

When does arterial insufficiency occur?

Answer 14

Within 12 hours post op

Question 15

When does venous insufficiency occur?

Answer 15

After 12 hours post op