Replantation Strategies Flashcards by M A

Postoperative anticoagulation and rehabilitation are important for achieving satisfactory functional restoration

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Any patient with any level of amputation from the fingertip to the
upper arm is a candidate for replantation

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Absolute Indications

■ Thumb
■ Multiple-digit
■ Transmetacarpal
■ Wrist
■ Forearm
■ Single digit in children
■ Individual digit distal to the flexor digitorum superficialis (FDS)
tendon insertion

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Relative Indications

■ Distal to distal interphalangeal joint (DIPJ)
■ Single digit proximal to the FDS tendon insertion
■ Local crushing or clear avulsion
■ Elbow and above elbow, sharply amputated or moderately avulsed
■ Patients ofadvanced age

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replantation beyond the level of the FDS tendon insertion, and zone
1 in a flexor tendon injury, usually results in satisfactory function

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The replantation of a single digit amputated proximal to the insertion
of the FDS is more indicative of revision amputation

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The flexor
and extensor tendons can adhere to the healing bone and require
secondary tenolysis to improve motion

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Digital replantation in children is no longer a challenging procedure, and survival rates are increasing

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amputation level and injury type are not considered as contraindications.

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Prolonged warm ischemia time is strongly correlated with contraindication to the replantation ofamputation at the proximal forearm or
upper arm.

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in normal ambient temperatures, irreversible changes can develop in
muscle within only 2 hours of ischemia

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digits do not
contain muscle and can tolerate much longer ischemic conditions

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recommended ischemic times for reliable success with replantation for digits,

12 hours of warm and 24 hours of cold ischemia

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6 hours ofwarm and 12 hours ofcold ischemia for major limb replants.

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Delayed or suspended replantation of the digits even after 48 hours
of cold ischemia time can be considered for patients with immediate
life-threatening injuries that can be stabilized during the first 24 hours

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Under loupe magnification, avulsed vessels reveal the ribbon sign (Figure 83.2B), demonstrating intimal injury by torsion and stretch on a vessel.

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Severe crushing or avulsion injury shows the
red line sign, which is a bruised line of the skin along the course of
neurovascular bundles

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dvanced age in itself is not a factor for contraindication of
replantation

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extreme contamination or multilevel or segmental amputation of the digit is regarded as a contraindication

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When the patient requests replantation despite one existing contraindication, hand and plastic microsurgeons should try to perform
replantation

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Blood typing
and crossmatching are necessary for all replantation

F for replantation of a major limb or
amputation of two of three digits or more

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Intensive care monitoring is necessary for complications caused by
massive transfusion as well as for maintaining the patient’s general
condition.

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Postoperative use of indwelling pain
catheters is not recommended why?

because of concerns about hematoma
formation secondary to anticoagulation protocols used following
replantation.

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general
anesthesia is usually preferable. in wich situation?

For proximal amputations above the elbow, younger children,
very nervous patients, patients on anticoagulants, and in prolonged
surgery such as in multiple-digit or bilateral amputations

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When should I use vien graft ?

If there are signs of arterial damage, including the telescope, cobweb, and ribbons signs or terminal thrombosis

Each finger has a dominant digital artery

The dominant artery of each finger is usually located in the radial side of the hand

F The dominant artery of each finger is usually located close to the midline of the hand

In the index finger, the ulnar digital artery is dominant, and in the little finger, the radial digital artery is dominant

In the middle and ring fingers, ulnar and radial digital arteries are dominant respectively,

The digital artery is always located on the dorsolateral aspect of the digital nerve

In the thumb, neurovascular bundles are located to both lateral sides of the mid-volar line

volar zigzag incisions are preferable WHY?

The longitudinal incisions over the vascular pedicles are sometimes difficult to close without compressing the pedicles It can be left partially open without exposure of vessels to accommodate swelling and can be extended proximally as far as necessary to identify undamaged artery and nerve

advantageous of the bone shortening procedure

it facilitates primary bone union, direct nerve repair, end-to-end vessel repair, and tension-free closure of the soft tissue without grafts. reduces the total operation time required for revascularization

Bone shortening of the amputated part is preferred to maintain the maximum stump length if the replantation fails

Acceptable length of the bone shortening is 0.5 to l cm of the digits

Spurting of the proximal artery should be checked under deflation of the tourniquet. Ifthe spurt is inadequate, additional shortening ofthe more proximal vessel is required.

bony fixation, extensor tendon repair, and flexor tendon repairs under inflation of the tourniquet, and then after deflation, arterial anastomosis, nerve repairs, venous repair, and skin closure can be carried out.

in most cases, bone shortening is essential as described before

The method of bone fixation depends on the fracture pattern and level of skeletal injury relative to the joints

it is not necessary to use plates and screws which is an acceptable but time-consuming technique

Bone fixation is usually achieved by using two parallel medullary axial Kirschner (K) wires, and two crossed K-wires or a single axial K-wire with an oblique wire to prevent rotational deformity.

longitudinal K-wires carry the disadvantage of not offering rigid fixation, not preventing rotation, and of passing through the joint

longitudinal K-wires should only be used in distal replants and revascularizations where other fixation methods may not be technically feasible.

The intraosseous 90-90 wiring technique is a quick and secure method of bony fixation for digital replantation

Advantage of intraosseous 90-90 wiring?

has the lowest nonunion and complication rate irrespective of supplemental fixation with K-wire.

Three sets of wires, two longitudinal and one radial ulnar, provide as much rigidity as a fixation plate

Before extensor tendon repair, dorsal periosteum should be sutured with 5-0 absorbable sutures

In amputations at the proximal phalanx, repair of the lateral bands of the extensor tendon is essential to achieve appropriate extension of the distal joints

in zone 2 injuries, repair of only the FDP tendon may be undertaken to avoid adhesions between the FDS and FDP tendon suture lines

Venting the sheath or pulley for a total of 1.5 cm in the areas close to the amputation level should be done to allow smooth gliding of the repaired tendon

arterial anastomosis should precede vein repair

Irrigation with heparinized solution at a concentration of 100 units/mL should be under 80 mm Hg ofpressure,

In cases of excessive tension or a definite segmental gap between the proximal and distal ends of the artery, interposition vein graft or shifting artery from the undamaged adjacent artery of the same or another finger is necessary

The use ofvein grafts is not as time consuming as much as commonly thought and is a straightforward and reliable technique

Using a vein graft easier than spending more time on the bone shorting

The use ofvein grafts is not as time consuming as much as commonly thought and is a straightforward and reliable technique

Maintaining venous drainage is the key to successful replantation because venous insufficiency is the most common cause of replantation failure.

It is preferable to repair both digital arteries and as many veins as possible for successful replantation

In a middle or proximal phalangeal replantation, anastomosis of one artery and two veins is sufficient

If two arteries have been repaired, two or more veins should be repaired

The volar skin of the digit is a useful site for vein repair rather than dorsal vien

T because it is less likely to be avulsed during injury and in amputations with tissue loss, and the size discrepancy is less for volar veins than for dorsal veins. It also does not require changes in hand position and it is indicated when primary repair of dorsal veins can be difficult due to tightness ensuing from arthrodesis of the underlying joint in flexion

Nerve regeneration is the most important prognostic factor in final functional recovery after replantation.

To prevent neuroma formation in replantation, nerve repair should be performed without tension

When a nerve graft is required what are the options ?

terminal branch of the posterior intraosseous nerve or medial antebrachial cutaneous nerve of the forearm is easily harvested from the ipsilateral side

Just one tight stitch can result in venous congestion

small split-thickness skin grafts can be applied, even directly over arterial or venous anastomosis or vein grafts

whereas a fall in the oxygen saturation below 90% usually indicates venous occlusion

the highest risk of postoperative thrombosis is in the first 72 hours after surgery

Arterial thrombi usually result from platelet aggregation and present on day 1

whereas venous thrombi result from fibrin clotting and usually present by day 2 or 3

Preoperative administration of aspirin decreases microvascular thrombosis formation

Heparin possesses properties of prevention of both platelet-induced arterial thrombi and coagulation-induced venous thrombi and vasodilatory effect, but it causes hematoma formation and induces thrombocytopenia.

The use of intravenous heparin does not correlate with higher success rates of replantation

heparin indicated in cases of intimal damage by crush and avulsion injuries, intraoperative thrombus, or following successful thrombolysis and arteriosclerotic changes

Before the release of microvascular clamps, heparin bolus of 50 to 100 U/kg is intravenously injected

early protected motion (EPM1) begins at approximately 5 to 14 days after replantation and consists of gentle wrist flex.ion and simultaneous finger extension by virtue of the tenodesis effect

EPM II begins at 7 to 14 days and consists of the intrinsic minus (hook) and the intrinsic plus (table) position

At 5 to 6 weeks, composite motion and functional activities are introduced

Strengthening begins at 6 to 8 weeks.

At the level of the eponychium, 63% of fingers have a vein of 0.8 mm or larger

Delayed venous drainage results in a high success rate in distal phalangeal replantation

In cases of impossible vein repair, there are suggested methods of salvage procedures

with external bleeding with a fish mouth incision or removal of the nail bed, medical leeches, continuous administration of heparinized saline, or creation of an arteriovenous anastomosis between the other distal digital artery and a proximal vein

including adequate sensory recovery.

propensity for vasospasm is more with pediatric age group

Replantation should consist of minimal bone shortening to preserve epiphyseal plates and simple bone fixation with longitudinal K-wires IN Pediatric

Recovery of sensibility in the replanted digit is nearly as good as for isolated digital nerve repair with Pediatric

The success rates of pediatric digital replantation have been reported to be as high as 95% to 97%,28.29 but proximal replantation is less favorable than digital replantation,

continued skeletal growth occurred and the digit attained 81% to 90% of normal longitudinal length at maturity unless significant damage to the epiphyseal plate is apparent

In thump arthrodesis is more generously accepted in cases of amputation around the IP or MCP joint

The thumb with IP fusion can still have useful motion through the MCP joint and carpometacarpal joint without repairing flexor pollicis longus (FPL) and extensor pollicis longus (EPL)

Microscopic focus on the ulnar artery of the thump at different levels is annoying because it requires extreme arm pronation or supination

is preferable to use a digit-by-digit replantation sequence rather than structure-by-structure replantation. in Multiple-Digit Replantation

good replantation order is the thumb first followed by the middle finger, the ring finger, index finger, and the small finger last

Maintenance of digital length is not a positive factor for the final functional result

in case of multiple-digit amputations including nonreplantable thumb, the least damaged digit should be replanted in place of the mutilated thumb

In cases of multiple-digit amputations with the thumb intact, the effort is made to replant the digits toward the ulnar side of the hand, so the width of the palm span is preserved and the power grip of the hand can be increased.

Cross-hand replantation or cross-arm replantation is aimed to save at least one hand or one limb used for pinch and grasping

Functional results after Transmetacarpal Replantation has good recovery

F have been mainly attributed to poor recovery of intrinsic muscle function

replantation at the MCP level is not technically difficult,

at least l cm of bony shortening is recommended to prevent secondary intrinsic tightness in the fingers in MCP replantation

Care must be taken during bony fixation to prevent malrotation of an individual digit

Hemostasis is particularly important at MCP replantation

where branches of the deep metacarpal arteries may bleed profusely. It should be identified both in the distal amputated part and in the amputation stump and ligated

The distal portions of devitalized and denervated interosseous muscles should be completely debrided, which can allow the intrinsic tendons to tenodese in an intrinsic-plus position.

A postoperative protocol should beinitiated 72 hours after replantation

cold intolerance remains a permanent problem in half of the patients in cold weather areas.

Intrinsic muscle function and pinch and grip strengths are weak or absent in most patients

In crush amputation cases, neovascularization of the replanted part occurs slowly. In these cases, replantation failures may happen after 1 week to 10 days postoperatively

In spite of successful replantation, the pulsation of Doppler and angiography reveals occlusion of the arteries in 37% of vessels after an average of 15 postoperative days.

Later, secondary reconstruction with toe-to-hand transfer is possible only where at least 1 cm of the middle phalangeal bone remains.

K-wire fixation having the highest nonunion rates.

screw fixation being associated with the highest rates of malunion.

there is no significant relationship between the return of sensibility and the length of ischemia time

Cold intolerance after replantation is a significant problem

cold intolerance results from a disorder in vasoregulation and not from arterial insufficiency of the digit.