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Ebopras > Replantation > Flashcards

Replantation Flashcards

1
Q

What are the current indications for digital replantation?

A

Thumb
Multiple digits
Single digit distal to sublimis
Hand at the wrist or forearm (sharp amputation)
Any level amputation in a child

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2
Q

What is the appropriate preoperative workup for a patient with an amputated digit?

A

Stabilize the patient.
Wrap amputated part in moist gauze and place in plastic bag, then place on ice. Administer intravenous antibiotics, and tetanus prophylaxis.
Radiographs of the involved hand and the amputated part.
Appropriate preoperative counseling and consent.

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3
Q

What is the order for a single digit replant?

A

BEFANV:
r Bone
r Extensors r Flexors
r Arteries
r Nerves
r Veins

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4
Q

What is the order for multiple digit replantations—digit by digit or structure by structure?

A

Structure by structure, systemically repairing as above.

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5
Q

What are the options for skeletal stabilization in digit replantation?

A

r Kirschner wires
r 90-90 wiring
r miniplates and screw
r intramedullary bone pegs

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6
Q

What are the functional deficits associated with ray amputation of the index finger?

A

Loss of power grip and key pinch.

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7
Q

What is the lumbrical plus deformity?

A

The FDP tendon and lumbrical muscle migrate proximally after division of the tendon in trauma. With flexion, tension is exerted on the lumbrical via the radial lateral band causing paradoxical extension of the PIP during flexion of the MP joint.

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8
Q

lumbrical plusTreatment?

A

Division of the lumbrical insertion.

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9
Q

What is the most common cause of digital replantation failure?

A

Arterial insufficiency.

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10
Q

What is the treatment of arterial insufficiency after digital replantation?

A
  1. if any concern about arterial patency RETURN to OR
  2. loosen dressings
  3. heparin
  4. anti-vasospastic medications (Thorazine) 5. sympathetic blocks
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11
Q

What is the treatment of venous congestion after digital replantation?

A
  1. removal of dressings
  2. leech therapy
  3. heparin
  4. nail bed bleeding with heparin-soaked sponges 5. revision of the venous anastomosis
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12
Q

Which tissue is most sensitive to warm ischemia?

A

Skeletal muscle.

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13
Q

What is the maximal cold ischemia time reported for digital replantation?

A

30 to 40 hours.

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14
Q

When should prophylactic fasciotomies be performed in upper extremity replantation?

A

With any replantation proximal to the wrist prophylactic fasciotomies should be performed because of the increased amount of skeletal muscle present.

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15
Q

What is the quadriga effect?

A

Weakness in flexion of fingers secondary to excess pull of one FDP tendon of the amputated finger.

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16
Q

What is the maximum nerve gap for use of a neural tube (PGA)?

A

2.5 cm.

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17
Q

What nerves are available for use as donors for nerve grafting?

A

r posterior interosseus nerve r sural nerve
r superficial radial nerve
r superficial peroneal nerve

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18
Q

What is the treatment of choice for a tip amputation through the nail bed without bone exposure?

A

Local dressings changes.

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19
Q

What is a good option for a thumb tip amputation with exposed bone?

A

Moberg flap.

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20
Q

How much advancement can be obtained from a Moberg flap?

A

1.5 cm.

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21
Q

What are contraindications to digital replantation?

A

r severe concomitant injuries r severely crushed or mangled r multilevel amputations
r significant comorbidities
r prolonged warm ischemia time
r mentally unstable/self-mutilation
r single finger proximal to FDS insertion

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22
Q

How many arteries and veins are needed for a digital replantation?

A

One artery and one Vein (two are preferred).

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23
Q

❍ Is an artery only digital replantation possible?

A

Yes. Leeching and/or bleeding of the nail bed can be used to relieve venous congestion.

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24
Q

❍ How many places can you find a digital vein?

A

Two. Dorsal and volar.

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25
Q

What is the concern in avulsion amputation versus guillotine amputation?

A

Zone of injury much greater in avulsion injuries.

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26
Q

What is the Chinese stripe sign or red stripe sign?

A

A red streak along the artery indicating severe intimal injury along the length of the vessel.

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27
Q

What is the best method for treating the zone of injury of an artery or vein in cases of crush or avulsion injuries?

A

Resection of compromised vessel and vein grafting.

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28
Q

Where can veins be reliably found on the hand dorsum?

A

Proximal to each web space.

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29
Q

What vascular pattern exists in a finger that was crushed and has the appearance of venous congestion and slow capillary refill?

A

Loss of proper digital artery inflow, intact venous flow.

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30
Q

Eight months post digital replantation, what operation would you offer to the patient with minimal passive or active ROM?

A

Extensor tenolysis and open capsulotomy.

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31
Q

What operation would you offer for someone with good passive but minimal active ROM?

A

Flexor tenolysis.

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32
Q

What is the greatest danger in digital reoperation after replantation?

A

Injury to the neurovascular bundle embedded in scar.

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33
Q

What is fluorimetry?

A

A method of monitoring tissue perfusion by injecting fluorescein dye intravenously and using a fluorometer to
quantitatively measure rise and fall of fluorescein in tissue.

34
Q

What if there is a 2- to 3-fold rise but no fall in the numbers?

A

Sign of venous congestion.

35
Q

What if the absolute number is very low and remains low, but the digit clinically looks viable?

A

Thick skin or dirty skin can alter the numbers.

36
Q

At the microanastomosis, what is the predominant layer on day 3?

A

Platelets.

37
Q

Ondays4to14?

A

Pseudointima.

38
Q

On day 14 onward?

A

Intima.

39
Q

One year postreplantation at the PIPJ level with severe arthritis or fusion at the PIPJ. What surgery can you
offer the patient?

A

PIP joint arthroplasty.

40
Q

What is the “No-reflow phenomenon”?

A

Inability to maintain perfusion to the replanted tissue despite restoration of blood flow through a technically
acceptable anastomosis. Thought to be the result of ischemia-induced endothelial injury.

41
Q

Scientific name for Medical Leeches?

A

Hirudo medicinalis.

42
Q

Action of hirudin?

A

r Binds activated thrombin (1:1).
r Inhibits conversion of fibrinogen to fibrin.
r Blocks activation of factors V, VIII, XI, vWF.
r Decreases activation of TPA, protein C, plasmin.
r Prolongs thrombin-dependent coagulation tests (PTT, TT, ACT, ECT). r There is no direct effect on platelets or endothelial cells.
r Can monitor by thrombin time and PTT.

43
Q

Excretion of hirudin?

A

Renal excretion.

44
Q

Organism to cover while patient is on leech therapy?

A

Aeromonas hydrophila—enteric organism that can cause severe soft tissue infection. Can cover with third-generation
cephalosporin (Cefizox), Bactrim.

45
Q

What is the mechanism of heparin?

A

Action is primarily via activation of serum antithrombin III and lowering of blood viscosity; increases AT III activity.

46
Q

What is the mechanism of dextran?

A

r polysaccharide—molecular weights of 40,000 and 70,000.
r decreases platelet aggregation by imparting a negative charge on the platelets, inactivating vWF.
r modifying structure of fibrin.
r altering rheologic property of blood.
r Possible complications: antigenic test dose of less than 5 mL must be given prior to administration of a full dose. r Renal failure—volume expansion.

47
Q

What is the mechanism of aspirin?

A

r acetylates cyclooxygenase enzyme
r decreases arachidonic acid, thromboxane, prostacyclin r decreases platelet aggregation and vasoconstriction

48
Q

What is the mechanism of Thorazine?

A

Potent vasodilator.

49
Q

What is the mechanism of papaverine?

A

Salt of an opium alkaloid. Smooth muscle relaxant especially with cerebral and peripheral ischemia associated with
arterial spasm.

50
Q

What is the mechanism of Lidocaine?

A

Potent local vasodilatation. Commonly used as a 2% solution.

51
Q

What is the definitive role of anticoagulation in microsurgery?

A

Controversial. Not enough randomized controlled trials to definitively characterize its role. Common uses: high-dose heparin irrigation during the microanastomosis. Intravenous heparin after a thrombotic event with anastomotic revision.

52
Q

What percentage of venous thrombotic events in the human body are caused by genetic factors?

A

Inherited deficiencies account for 5% to 15% of venous thrombosis.

53
Q

Is the antiphospholipid antibody associated with arterial or venous thrombosis?

A

It is associated with both.

54
Q

What is activated protein C resistance (APC/Factor V Leiden)?

A

r One of the most common hereditary causes of thrombophilia.
r 4% frequency in European population, extremely uncommon in Africans, Asians, and Australians. r APC inactivates Factors V and VIII—keeps thrombosis in check.

55
Q

What is a prothrombin 2021A mutation?

A

r relative risk of thrombosis with this mutation is 2.8
r prevalence—2%
r extremely uncommon in nonwhite population
r treatment: Coumadin 3 to 6 months; recurrence—indefinitely

56
Q

What is hyperhomocysteinemia?

A

Usually an enzyme deficiency in states of chronic renal disease, hypothyroid, malignancy. r Can be associated with medications.
r Strong correlation between elevated homocysteine levels and arterial and venous disease. r Arterial—increased cardiac, cerebral vascular disease; 3× risk.Venous—increased risk of thrombosis

57
Q

How much does an elevated Factor VIII cause a hypercoagulable state?

A

Levels greater than 1,500 IU/L lead to a 5× increase of thrombosis.

58
Q

Does an elevated Factor XI cause an increased rate of thrombosis?

A

Yes. Relative risk 2.2.

59
Q

What is the workup for hypercoagulable states?

A

Be suspicious when patient has a thrombotic event early in life (age <45), family history, recurrence.
Lab studies to order: Antithrombin III, proteins C and S, antiphospholipid antibody, Factor V Leiden, prothrombin 2021 A mutation, homocysteinemia. Involve a hematology oncologist early.
Note: Proteins C and S and antithrombin III are decreased in acute thrombosis; antithrombin III decreased during heparin.

60
Q

Which Urbaniak class of ring avulsion injury is considered a relative contraindication to replantation?

A

III—complete degloving or complete amputation.

61
Q

What type of flap can be used if there is a soft tissue defect in a Type II ring avulsion injury?

A

Venous flow through flap

62
Q

What is the average 2PD of a replanted thumb?

A

9 to 11 mm.

63
Q

What is the average 2PD of a replanted digit?

A

8 to 15 mm—depending on sharp versus avulsion.

64
Q

How much time should you tell a patient he will have to wait for cold intolerance symptoms to resolve?

A

At least 2 years, possibly a lifetime.

65
Q

What is the typical history of a scalp amputation?

A

Young female factory worker with long hair, with avulsion of scalp along the supraorbital rim extending to the ears
laterally and to the nape of the neck posteriorly.

66
Q

Which vessels are commonly used for replantation?

A

r superficial temporal r posterior auricular r occipital
r supraorbital
Usually a single artery and vein can be used to replant the scalp. Vein grafts are commonly used.

67
Q

What is a common complication after scalp replantation?

A

Hematoma.

68
Q

Which vessels are commonly used in ear replantation?

A

Superficial temporal or posterior auricular.

69
Q

Venous drainage ear?

A

Veins are extremely difficult to find and most often, the ear has to be leeched.

70
Q

What options exist if the amputated part is not replantable? ear

A

Banking of ear cartilage for future ear reconstruction.

71
Q

What is the “pocket principle”?

A

The epidermis is removed from the severed part, leaving the cartilage covered by a thick layer of dermis. The part is then attached to its original position. A retroauricular incision is made and a subcutaneous pocket is created large enough to accommodate the ear. The ear is removed in 2 to 4 weeks.

72
Q

Which arteries to look for in a lip replantation?

A

Labial arteries.

73
Q

Veins in lip replantation?

A

Extremely difficult, usually requires leeching.

74
Q

Most common cause of lip amputation?

A

Dog bite.

75
Q

Can the tongue be replanted?

A

Yes. Three have been reported in the world literature.

76
Q

Although lower extremity replantation remains controversial, indications to proceed with replantation include?

A

r patient age (children do better with neurological regeneration) r overall condition (comorbidities and associated injuries)
r ischemia time <6 hours
r type and extent of injury (guillotine, single level)
r bilateral amputations

77
Q

What can you do with the remaining amputated leg if replantation is not possible at a below knee
amputation site with significant soft tissue loss?

A

Foot fillet flap.

78
Q

Common cause of penile amputation?

A

Self-mutilation.

79
Q

Vessels in penile replantation?

A

Dorsal vein and deep arteries in corpora.

80
Q

What adjunctive therapy can be used to assist with ischemic tissues after replantation?

A

Hyperbaric oxygen therapy.

Ebopras (32 decks)

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