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Plastic Surgery( Grabb)Ali jasim > Replantation Strategies > Flashcards

Replantation Strategies Flashcards

1
Q

Postoperative anticoagulation and rehabilitation are important for achieving satisfactory functional restoration

A

T

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2
Q

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

A

T

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3
Q

Absolute Indications

A

■ 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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4
Q

Relative Indications

A

■ 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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5
Q

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

A

T

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6
Q

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

A

T

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7
Q

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

A

T

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8
Q

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

A

T

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9
Q

amputation level and injury type are not considered as contraindications.

A

T

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10
Q

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

A

T

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11
Q

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

A

T

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12
Q

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

A

T

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13
Q

recommended ischemic times for reliable success with replantation for digits,

A

12 hours of warm and 24 hours of cold ischemia

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14
Q

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

A

T

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15
Q

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

A

T

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16
Q

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

A

T

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17
Q

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

A

T

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18
Q

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

A

T

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19
Q

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

A

T

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20
Q

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

A

T

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21
Q

Blood typing
and crossmatching are necessary for all replantation

A

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

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22
Q

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

A

T

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23
Q

Postoperative use of indwelling pain
catheters is not recommended why?

A

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

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24
Q

general
anesthesia is usually preferable. in wich situation?

A

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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25
Q

When should I use vien graft ?

A

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

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26
Q

Each finger has a dominant digital artery

A

T

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27
Q

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

A

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

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28
Q

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

A

T

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29
Q

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

A

T

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30
Q

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

A

T

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31
Q

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

A

T

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32
Q

volar zigzag incisions are preferable WHY?

A

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

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33
Q

advantageous of the bone
shortening procedure

A

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

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34
Q

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

A

T

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35
Q

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

A

T

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36
Q

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.

A

T

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37
Q

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.

A

T

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38
Q

in most cases, bone shortening is essential as described before

A

T

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39
Q

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

A

T

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40
Q

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

A

T

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41
Q

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.

A

T

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42
Q

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

A

T

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43
Q

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

A

T

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44
Q

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

A

T

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45
Q

Advantage of intraosseous 90-90 wiring?

A

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

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46
Q

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

A

T

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47
Q

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

A

T

48
Q

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

A

T

49
Q

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

A

T

50
Q

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

A

T

51
Q

arterial anastomosis should precede vein
repair

A

T

52
Q

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

A

T

53
Q

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

A

T

54
Q

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

A

T

55
Q

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

A

T

56
Q

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

A

T

57
Q

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

A

T

58
Q

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

A

T

59
Q

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

A

T

60
Q

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

A

T

61
Q

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

A

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

62
Q

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

A

T

63
Q

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

A

T

64
Q

When a
nerve graft is required what are the options ?

A

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

65
Q

Just one tight stitch can result in venous congestion

A

T

66
Q

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

A

T

67
Q

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

A

T

68
Q

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

A

T

69
Q

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

A

T

70
Q

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

A

T

71
Q

Preoperative administration of aspirin decreases microvascular
thrombosis formation

A

T

72
Q

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.

A

T

73
Q

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

A

T

74
Q

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

A

T

75
Q

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

A

T

76
Q

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

A

T

77
Q

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

A

T

78
Q

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

A

T

79
Q

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

A

T

80
Q

Strengthening begins
at 6 to 8 weeks.

A

T

81
Q

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

A

T

82
Q

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

A

T

83
Q

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

A

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

84
Q

including adequate sensory recovery.

A

T

85
Q

propensity for vasospasm is more with pediatric age group

A

T

86
Q

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

A
87
Q

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

A

T

88
Q

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,

A

T

89
Q

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

A

T

90
Q

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

A

T

91
Q

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)

A

T

92
Q

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

A

T

93
Q

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

A

T

94
Q

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

A

T

95
Q

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

A

T

96
Q

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

A

T

97
Q

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

A

T

98
Q

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.

A

T

99
Q

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

A

T

100
Q

Functional results after Transmetacarpal Replantation has good recovery

A

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

101
Q

replantation at the MCP level is not
technically difficult,

A

T

102
Q

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

A

T

103
Q

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

A

T

104
Q

Hemostasis is
particularly important at MCP replantation

A

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

105
Q

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

T

106
Q

A postoperative protocol should beinitiated 72 hours after replantation

A

T

107
Q

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

A

T

108
Q

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

A

T

109
Q

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

A

T

110
Q

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.

A

T

111
Q

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

A

T

112
Q

K-wire fixation having the highest nonunion rates.

A

T

113
Q

screw fixation being associated
with the highest rates of malunion.

A

T

114
Q

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

A

T

115
Q

Cold intolerance after replantation is a significant problem

A

T

116
Q

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

A

T

Plastic Surgery( Grabb)Ali jasim (92 decks)

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