13. Bony fixationBony fixation
External/internal fixation
Shortening may be performed
◦ (to allow primary repair of nerves n
vessels)
Bone grafting in gaps>3cm
Vascularized bone graft in gaps>6cm
13
14. Tendon RepairTendon Repair
Tendon grafts
◦ PL, plantaris, toe extensor
Tendon transfers
◦ Recon of EPL with EIP transfer
Free tendocutaneous flap
◦ PL, FCR from contralateral arm
Allograft tendon
14
15. Nerve reconstructionNerve reconstruction
As soon as possible
Primary repair
◦ Sharp injuries
Nerve Grafting
◦ Crushed , avulsed injuries
Primarily repaired nerves have better
sensory and motor recovery
Younger age, distal injury, and earlier
time of repair associated with better
motor recovery 15
22. HistoryHistory
Balfour provided the first scientific report of digital
reattachment in 1814
Murphy in 1896 reported the first successful critical
arterial repair.
Kleinert performed the first successful extremity
revascularization in 1958
Malt performed the first successful extremity
replantation in 1962
Komatsu and Tamai performed the first successful
replantation of completely amputated digit with
microsurgical anastomosis in1965
23
23. INTRODUCTIONINTRODUCTION
Not all patients with amputation are
candidates for replantation
Decision based on:
Importance of the part
Level of injury
Expected return of function.
Hand function is severely compromised if
thumb or multiple fingers are lost so
replants of these should be attempted.
Mechanism of injury may be the most
predictive variable for successful
replantation.
24
24. Indications for replantationIndications for replantation
Strong indications
• Multiple digital amputations
• Thumb amputations
• Whole hand
• Transmetacarpal and partial hand amputations
• Any amputated part in a child
• Single digit amputation distal to FDS insertion
Relative indications
• Sharp injuries at elbow or proximal forearm
• Humeral-level amputations
25
25. Relative contraindications toRelative contraindications to
replantationreplantation
• Concomitant life-threatening injury
• Systemic illness (e.g., small-vessel disease)
• Poor anesthesia risk including old age (>70 yrs)
• Mentally unstable patients
• Single finger proximal to FDS insertion in adults
• Multiple segmental injuries in the amputated part
• Severe crushing or avulsion of the tissues
• Extreme contamination
• Prior surgery or trauma to the amputated part
• Prolonged warm ischemia time
• Ribbon sign, red line sign
• smoker/drug abuse 26
27. 28
Replantation center criteriaReplantation center criteria
1. An efficient ground and air transportation system
2. Experienced microsurgical teams
3. A well-prepared emergency room staff
4. Experienced anesthetists, operating room, and
microsurgical staff available 24 hours/day, 7
days/week
5. Proper microscopes, instruments, and sutures
6. A carefully trained nursing staff for postoperative
care and monitoring
7. Physical and occupational therapists trained in
28. Preoperative ManagementPreoperative Management
Transfer to a replantation center:
◦ Amputation stump:
covered with a saline-moistened gauze, loosely
wrapped, and elevated
Compression bandages may be required to
stop bleeding
29
31. Preoperative ManagementPreoperative Management
Management in ER:
◦ Resuscitation and stabilization of pt
◦ Control bleeding
◦ Brief history
◦ X-rays of amputated part & proximal
stump
◦ Routine investigations
◦ Tetanus prophylaxis
◦ Prophylactic antibiotics
32
32. Preoperative ManagementPreoperative Management
Evaluation for replantation:
◦ Complete amputation:
Take amputated part to OR
Dissect, isolate & tag imp structures
◦ Incomplete amputation:
If held by only strands, divide them
If a skin bridge is present,keeping it is
important
33
33. Recommended ischemia times for
reliable success:
◦ Digit: 12 hours for warm ischemia and 24
hours for cold ischemia.
◦ Major replant: 6 hours of warm and 12
hours of cold ischemia.
Preoperative preparation:
radiography of both amputated and
stump parts to determine the level of
injury and suitability for replantation
34
34. Operative ManagementOperative Management
Team approach
◦ to avoid surgeon fatigue
Regional anesthesia alone or in
combination with general anesthesia
Patient preparation:
Catheterization, padded tourniquet ,lower limb
preparation, temperature, padding all bony
prominences
35
35. Operative ManagementOperative Management
Arterial or venous repair first?
Vein first minimizes blood loss and completes the most
difficult step
artery first allows selection of veins with good outflow for
anastomosis
Bench work:
debridement, isolation of NV structures & bone
shortening
performed with the amputated part on ice pack
digits unsuitable for replantation should not be discarded
vessels & nerves tagged with small metal clips or 8-0
sutures
36
42. Operative ManagementOperative Management
Arterial repair:
Repair both arteries
Dominant artery
vein graft, cross anastomosis (radial digital
artery to ulnar digital artery) or transposition of
a digital artery from one of the adjacent fingers
43
43. Operative ManagementOperative Management
Nerve repair:
tension-free nerve repair with 8.0 suture
posterior interosseous nerve for small gaps
medial antebrachial cutaneous nerve for longer defects
Graft from discarded digits
Skin closure:
Meticulous hemostasis and the skin flaps losely
approximated
local skin flaps
Skin grafts
In major limb replantations, a prophylactic fasciotomy
is performed to decompress TH, HTH, dorsal IO
spaces ,CT, forearm muscle compartments
44
47. Postoperative ManagementPostoperative Management
Postop care
highest risk of postop thrombosis is in the first
72 hours
Arterial thrombi present on day 1,
venous thrombi present by day 2 or 3.result
from fibrin clotting
NPO for 24 hrs
Preventing extrnal factors resulting in spasm
and thrombosis
Warm, hydrated, elevated, pain free,avoid
smoking & caffeinated drinks
Antibiotics for 5-7 days
48
48. Postoperative ManagementPostoperative Management
Anticoagulation:
a 100 mL bolus of dextran-40 intravenously
prior to release of the vascular clamps,
Followed by a continuous infusion of dextran-
40 at 500 mL per day for 5 days (10 ml/kg/day).
A 5,000 unit bolus of heparin after removal of
the arterial clamp.
once-daily dose of 100 mg of aspirin that is
continued for 3 weeks
continuous low-dose heparin infusion for 3 to 4
days for smokers
49
49. Postoperative ManagementPostoperative Management
Monitoring:
monitor perfusion by examining color, pulp turgor,
capillary refill and temperature.
hourly for the first 72 hours (3 days) and once every 4
hours for the next 48 hours (2 days).
soft (flaccid), pale fingertip with a delayed capillary refill
(>2 seconds) indicates arterial vasospasm or thrombosis
A swollen (turgid) blue finger tip with rapid capillary refill
(<1 second) indicates venous thrombosis.
pulse-oximeter probe secured to the pulp
loss of the pulse rate indicates arterial occlusion,
whereas a fall in oxygen saturation below 90% indicates
venous occlusion
50
50. Postoperative ManagementPostoperative Management
Monitoring:
lf there is a suspicion of compromised
perfusion,immediate action is taken
usually a thrombosis of an anastomosis that
invariably requires the use of an interposition
vein graft.
consider the use of leeches
or encourage continuous venous bleeding from
the nail bed by removing a portion of the nail
bed and repeatedly applying heparin-soaked
pledgets
51
51. Postoperative ManagementPostoperative Management
Therapy:
◦ Hand therapy can be started about a week after
replantation, once anticoagulation is stopped
◦ dorsal splint is provided and the patient started on gentle
active range of motion exercises.
◦ continued upto 2 to 3 months postoperatively
52
53. OUTCOMEOUTCOME
Overall success rates for replantation approach 80%.
Better outcome with Guillotine (sharp) amputation (77%)
compared to severely crushed and mangled body parts(49%).
The best results are obtained in replantation of the thumb,
fingers amputated distal to the insertion of the FDS, and the
hand through the wrist or the distal forearm.
Studies have demonstrated that patients can expect to achieve
50% function and 50% sensation of the replanted part.
Outcome is monitored by scoring system introduced by Tamai
and chen
54
MESS is a cumulative score with points given for skeletal/soft tissue injury,limb ischemia, shock, and age. MESS seems to be a better predictor of limbs that will not require amputation than of those that will
Initial management in the OR is dictated by the extent of vascular compromise. Critical warm ischemia times vary from tissue to tissue. Extremities with warm ischemia require immediate vascular reconstruction with concomitant fasciotomies.
Shunt placed from radial artery to radial artery to perfuse limb while debridement and bony fixation r performed
Initial soft tissue management may consist of debriding devitalized or heavily contaminated tissues with plans for subsequent debridement until the tissues appear clean and healthy enough for wound coverage or closure.
Following debridement, if vascular reconstruction is still required, the surgeon may consider whether this should be performed before or after bony fixation. Many surgeons believe that fracture fixation should precede definitive vascular reconstruction due to the risk of injury to reconstructed vessels However, revascularization may be performed safely prior to fracture fixation and may help avoid fascoitomyfor injuries with shoter ischemia time
Bony fixation may consist of external fixation, internal fixation, or a combination of the two techniques. In the acute setting shortening may be performed to prevent the need for bone grafting as well as to allow primary repair of debrided nerves and vessels and allow improved soft tissue defect management.
Tendon loss may be treated by tendon grafts or tendon transfers. Tendon grafts should not be performed under skin grafts or have skin grafts placed upon them, due to poor graft and wound healing combined with poor tendon excursion
Nerve reconstruction should begin when the wound is clean and coverage can be provided at the same time. All nerve repairs and reconstructions should be performed as soon as possible. Final motor recovery has been directly correlated with time to grafting of nerve injuries, with the best outcomes resulting from earlier reconstruction
Depends on extent of injury
Any concern for compartment syndrome necessitates a fasciotomy of the injured limb. fasciotomy rates stx:adily declined The exact causes are unknown but presumed to be improvements in resuscitation protocols and fluid management
Mangled upper extremity injuries are complex and require reconstruction of skin and soft tissue, nerve, vascular, and bony structures simultaneously. This requires a multidisciplinary surgical team, involving vascular, orthopedic, and plastic surgeons
“Ribbon” sign in an avulsed finger. Note corkscrewing of vessel which indicates severe avulsion damage to the adventitial layer. Red line sign: disruption of branches of digital artery.
to help the patient cope with his or her injuries and continue an active and useful life
Replantation surgery takes a long time, such as 6 to 8 hours for a major limb replantation and 2 to 5 hours for a more distal amputation. In multiple digital amputations, each digit can take up to 3 to 4 hrs.
logical sequence is to progress from repair of the deeper structures (bone and tendon) to superficial structures (nerve and vessels) and from repairs requiring gross manipulation (bone and tendon) to those that need an operating microscope (nerve and vessels) for fine precise repairs. The exact order of repair depends on surgeon preference and the level of amputation
Exposure of the venous plexus on the dorsum of the finger by raising a thick dorsal skin flap superficial to extensor tendon
after debridement. identification, and tagging of all structures, the tourniquet is deflated to assess the force of arterial inflow.
Mobilization of the veins by dividing side branches or dissecting a vein of sufficient length from the dorsum of an adjacent digit will permit tension-free primary repair.
Every attempt is made to repair both digital arteries. lf a single artery is being repaired,the dominant artery is repaired preferentially
Adequate bone shortening usually allows a tension-free nerve repair. If a single 8.0 suture is unable to hold the nerve ends together, a nerve graft is considered.
Appearance after carpal tunnel release and fasciotomy of muscular compartments following a distal forearm replant
All wounds are covered with a vaseline gauze and a soft, bulky dressing. Care is taken to avoid circumferential compression by the dressing, which when saturated with dried blood can become constrictive. The extremity is immobilized in a plaster splint and elevated.
increase blood flow or decrease blood viscosity (e.g., dextran);
