Major limb replantation in children

After the first successful replantation of a completely amputated extremity in a 12-year-old boy undertaken by Ronald Malt at the Massachusetts General Hospital in 1962 (Malt and McKhann, Journal of the American Medical Association, 189:716–722, 1964) numerous series of major limb replantations have been reported in adults. The reports of major limb replantation in children are relatively rare and are usually included in adult series. During the last 14 years, 18 children with major limb amputations were treated at the Microsurgical and Replantation Unit of the Department of Orthopaedic Surgery at the University of Ioannina Medical School. Of these, 13 were complete amputations (11 upper extremity and 2 lower extremity), while 5 were incomplete nonviable amputations (3 upper extremity and 2 lower extremity). The success rate following replantation of the complete amputations was 76.9%, while for the incomplete, nonviable amputations success was 80%. Preoperative evaluation, operative management, postoperative care, and the results of this difficult but rewarding procedure are analysed and discussed in this review. © 1994 Wiley-Liss, Inc.     

Alternatives to thumb replantation in three cases of traumatic amputation of the thumb

Three cases of complete amputation of the thumb are reported in which the amputated distal parts were not suitable for replantation. In all cases there were either complete or incomplete amputations of other digits. Two different techniques were used for thumb reconstruction: 1) pollicization of a partially amputated digit with transposition microsurgery in case 1; and 2) replantation of a less important amputated digit to the thumb stump for cases 2 and 3. These microsurgical efforts successfully restored thumb function in all three patients.     

Genesis of a replantation program

Development of a replantation program entails establishment of microsurgical skills in the laboratory, training in clinical microvascular technics, supervision, if possible, in the first microvascular free flaps, and close liaison with supporting personnel who transport patients, care for them acutely, and carry out their rehabilitation. Of twenty-six replantations or revascularizations (14 incomplete and 12 complete), twenty-three were successful. The three failures (1 complete and 2 incomplete procedures) were all digits, and each was part of a multiple digit injury.     

Artery only microanastomosis in nose replantation: a report of two cases

The nose is a central, prominent unit of the face. The surgical approach to complete nasal amputations is challenging and an experienced microsurgical team should always attempt microvascular replantation. This one-stage procedure could result in a superior clinical outcome compared to delayed reconstructive procedures. Two successful microvascular replantations of the distal half of the nose were performed. Both amputations were the result of two completely different aetiologies (sharp guillotine-like vs. avulsion trauma). However, we were not able to re-establish the venous drainage, which was managed through medicinal leeching. Both replantations resulted in an aesthetically pleasing result and no additional surgery was needed. A microsurgical replantation attempt should always be attempted in nasal amputations and the inability to perform venous anastomosis should not preclude the replant attempt.     

Bilateral thumb amputation

Seventy-one patients with thumb amputations, 45 complete and 26 incomplete nonviable, have been treated at the Microsurgical Unit of the Department of Orthopaedic Surgery at the University of Ioannina Medical School over the past 15 years. Of these thumb amputations, which included crush, avulsion, and guillotine injuries, three cases involved amputation of both thumbs. The three patients with complete bilateral thumb amputations are presented. Because of the importance of the thumb, microsurgical replantation efforts were made which proved successful for two of the patients. Replantation efforts in the third patient, who had severe crush injuries of both thumbs, were not successful. Bilateral thumb amputation is a serious and disabling injury. When replantation is attempted by a team of surgeons well trained in microsurgery, the final result can be impressive, with exceptionally good function of the replanted thumbs. © 1994 Wiley-Liss, Inc.     

Replantation and revascularization of hands: clinical analysis and functional results of 261 cases

During the past 4 years we performed 261 replantations and revascularizations on amputated digits and hands in 153 patients. The overall survival rate was 82%. Clean-cut proximal level amputations and hypothermically preserved amputation parts had the highest survival rate. A higher survival rate and more satisfactory results with accelerated return of sensory function correlated with repair of both digital arteries and two veins rather than only one. All patients experienced intolerance to cold, but this was more troublesome in patients with digital replantation in whom only a single artery was repaired. Digital sensibility and joint motion after replantation were better in these patients who had sharp amputations and on whom repairs were carried out in zone III. Return of intrinsic muscle function after hand replantation was poor; however, patient satisfaction with the procedures remained high.     

Restoration of basic hand function by double transpositional digital replantation in five-digit amputations

In multiple digital amputations with severe crush injury, replantation of digits with a poor prognosis is often fruitless. Those digits with a favorable prognosis should be selectively replanted in positions that provide optimal functional outcome, regardless of their anatomic origins: this is the principle of transpositional replantation. The authors present a case of right-hand crush injury with amputation of all five digits. Basic hand function was restored by double transpositional digital replantations without additional reconstructive procedures. In properly selected cases, such procedures can preserve greater hand function and reduce the necessity for secondary operations. It is suggested that transpositional replantation should be considered when multiple digital amputations are encountered.     

Transpositional replantation of digits. Case reports.

Heterotopic or transpositional replantation of digits is technically feasible with results similar to those of conventional replantation procedures. Occasionally in multiple digital amputations not all the digits may be replanted in their correct place as a result of complex injuries proximal to the amputation zone or severe damage to important fingers. In these circumstances the amputated digits that are in the best condition as regards undamaged tissue are used for replantation. The primary priority is an optimal functional outcome and the secondary priority the cosmetic outcome. Amputated long digits will always be used to substitute for a non-replantable thumb rather than to replace a long finger. We present 13 cases of successful transpositional digit or joint replantations in traumatic amputations of more than one digit.     

TRANSPOSITIONAL REPLANTATION OF DIGITS: Case reports

Heterotopic or transpositional replantation of digits is technically feasible with results similar to those of conventional replantation procedures. Occasionally in multiple digital amputations not all the digits may be replanted in their correct place as a result of complex injuries proximal to the amputation zone or severe damage to important fingers. In these circumstances the amputated digits that are in the best condition as regards undamaged tissue are used for replantation. The primary priority is an optimal functional outcome and the secondary priority the cosmetic outcome. Amputated long digits will always be used to substitute for a non-replantable thumb rather than to replace a long finger. We present 13 cases of successful transpositional digit or joint replantations in traumatic amputations of more than one digit.     

Reconstructive microsurgery in pediatric population-a series of 25 patients

Pediatric microsurgery procedures possess various difficulties when compared with adults. However, both free tissue transfers and replantation of the amputated parts show remarkable success rates in children. The concerns of survival of the flaps and the amputated parts have shifted to the function of these in the adulthood. Several key points and hints allow successfull rates for both survival and function. We present a series of microsurgical procedures both free tissue transfers (12 patients) and digital replantations (13 patients). Free tissue transfers included toe-to-hand transfers in 5, latissimus dorsi flaps in 4, fibular flaps in 4, and anterolateral thigh flaps in 2 patients. Thirteen patients involved 17 digital replantations. The survival rate was less in the replantation group (58.75%) than in the free tissue transfer group (93%). Both the functional and the cosmetic results were promising. The follow-up period was between 1 and 6 years (mean 37 months) for the free tissue transfer group and 1-5 years (mean 20 months) for the replantation group. The major technical difficulties include the age group of 0-2 years. Aside from these the high capacity of regeneration and the improved learning capacity increase the feasibility of the microsurgical procedures proceeded among children.     

Replantation and reconstructive microvascular surgery. Part I.

Although the operating microscope was introduced more than 50 years ago, its use was at first confined to otolaryngology and, later, to ophthalmology. More recently its use in the development of microvascular techniques has led to spectacular advances in the field of replantation and reconstructive surgery. The organization of microsurgical research at St Vincent''s Hospital, Melbourne, is briefly described and clinical experience at this hospital over the past 10 years is reviewed. This includes 86 cases of digital replantation, with survival rates of 58% for complete and 82% for incomplete amputation, and 14 cases of major replantation (amputations proximal to the metacarpophalangeal joints) with a survival rate of 71%. In the second part of the lecture the use of microsurgery for composite tissue transfer and one-stage toe-to-hand transfer is discussed and experimental and clinical experience in microlymphatic surgery described.     

Solutions to challenging digital replantations

Replantation of amputated digits remains one of the most challenging areas in plastic and reconstructive surgery. Complicated cases of digital amputation, such as fingertip amputations, multidigital amputations, and so forth, pose an even greater challenge, requiring extraordinary solutions for successful replantation. The authors present their experience with complicated digital replantations at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School. Cases presented include fingertip replantation, replantation of a finger with impairment of arterial inflow, and two cases of multidigital amputations. In one case of multidigital amputation, heterodigital replantation was performed, and in the other case, a minute skin neurovascular free flap from a nonreplantable finger was used for the reconstruction of another injured finger. Presented cases demonstrate various tools that can be successfully used in the performance of challenging digital replantations.     

Primary surgical treatment of amputated fingers and indications for digital replantation

The amputation of a single finger, or its part, or more fingers results in functional and esthetic changes in the patient's life. Until 1965 when the first thumb ever was replanted, the treatment of amputated digits had been limited by technical facilities of the medical science. Since 1970s, the development of fine suture materials, microsurgical instruments and the operating microscope has made it possible that replantations have become routine procedures in hand surgery. Both surgical procedures and indication schemes have also evolved. The primary surgical treatment has been standardized to involve the wrapping of amputated parts in dressing material saturated with isotonic solution and cooling at 4 to 10 degrees C during transport. The first enthusiasm for replantation of everything that had been amputated was replaced, owing to long-term post-operative results, by a more selective approach. Even an absolute indication for digital replantation, such as amputation of a thumb, two or more fingers, amputation in the palm and all amputations in children, must be put aside when life-threatening injuries or serious diseases are present. The benefit of replantation should always outweigh the trauma of any operative procedure because this must not harm the patient.     

Replantation and revascularization vs. amputation in injured digits

Background

The purpose of this study was to analyze factors associated with the decision to replant or revascularize rather than amputate an injured digit as well as factors associated with successful replantation or revascularization.

Methods

We reviewed 315 complete and subtotal amputations at or proximal to the distal interphalangeal joint in 199 adult patients treated over 10 years. Ninety-three digits were replanted (30 %), 51 were revascularized (16 %), and 171 were amputated (54 %), including 5 attempted replantations. Bivariate and multivariable analyses sought factors associated with replantation vs. amputation, revascularization vs. amputation, and success of replantation or revascularization.

Results

Factors associated with replantation rather than amputation were injury to the left hand, thumb, middle digit, and ring digit, more than one digit affected, and surgeon. Factors associated with revascularization are surgeon and shorter ischemia time. Forty-five replantations (48 %) and 41 revascularizations (80 %) were successful. Successful replantation was associated with the side of injury (left side more likely to survive), zone of injury (distal interphalangeal and interphalangeal joint more likely to survive and proximal phalanx less likely to survive), and shorter ischemia time. Success of revascularization was associated with the mechanism of injury (saw and not crush injury), multiple digits involved, and the surgeon.

Conclusions

The decision to replant, revascularize, or amputate a nonviable digit and the success of replantation and revascularization are related to both injury factors, such as mechanism of injury, affected digit, and zone of injury, and the surgeon.     

Replantation of the upper extremity: Indications and outcomes

Since the introduction of microsurgical technique over 40 years ago, replantation of the upper extremity has been performed throughout the world with regularity. Instead of focusing solely on survival of the replanted parts, hand surgeons are more aware of the functional, health-related quality of life and economic issues associated with this complex procedure. Derived from several decades of experience, the indications for replantations in the upper extremity have become more defined and the functional outcomes have improved. In indicated cases, replantation procedures provide patients with reconstruction that is unmatched by any other means. This article discusses the current status of replantation and condenses the particulars of performing upper-extremity replantations. Copyright © 2002 by the American Society for Surgery of the Hand     

Nonmicrosurgical replantation using a subcutaneous pocket for salvage of the amputated fingertip

PURPOSE: The pocket principle suggested by Brent in 1979 is an alternative method for use when microsurgical replantation is not feasible. The application and the amputation level for which the method is available, however, have not been well examined. METHODS: Between 1999 and 2003 we treated 6 patients (7 fingers) by nonmicrosurgical replantation using a subcutaneous pocket (the Brent technique). All patients had sustained complete fingertip amputations across or proximal to the lunula in digits other than the thumb. In every case the amputation was a crush or avulsion-type injury and microsurgical replantation was not feasible; however, cosmetic symmetry was desired strongly by the patient. RESULTS: Of the 7 fingers only one survived completely but became atrophic after 4 months. One finger developed necrosis involving less than half of the replant but a hooked nail deformity developed. Two fingers developed partial necrosis involving more than half of the replant but both fingers were missing the fingernail and the cosmetic results were not acceptable. Three fingers developed total necrosis. In addition a slight flexion contracture not improved with therapy in the digits was noted in 4 patients. CONCLUSIONS: The Brent technique should be performed scrupulously for fingertip amputation across or proximal to the lunula because of the poor survival rate and the possibility of contracture in the digits or other proximal joints.     

Indications and selection for digital amputation and replantation

Even though replantation surgery has now become a routine procedure, it remains delicate and demanding surgery, requiring adequate training and expertise in microsurgical techniques. Well-defined selection criteria for replantation procedures have evolved over the past few years, including definitive guidelines for thumb, single digit, multiple digit and mid-palm amputations. For more complex cases, other techniques, including transpositional microsurgery and various secondary reconstructive procedures, such as toe-to-hand transfer, are now available. Although replantation procedures have been simplified, a second surgical team can save valuable surgical time by debriding and identifying the vessels in the amputated part, harvesting microvenous grafts, and performing bone fixation or tendon repair among other things, while the chief surgeon focuses on revascularization. Overall, the most significant guideline underlining the philosophy of digital replantation today reflects the aim of not only ensuring the survival of a digit, but its functional use as well. Experience dictates that this can be achieved only if the basic principles and indications of replantation surgery are adhered to.     

Validity of exploration for suitable vessels for replantation in the distal fingertip amputation in early childhood: Replantation or composite graft

Abstract

Composite grafting, grafting without microvascular anastomoses, has been widely performed for distal fingertip amputation in children with variable results, whereas successful replantation of these amputations using microsurgical technique has been reported. However, most of these reports included a wide age-range and a mix of different amputation levels. This study reviewed our cases of paediatric digital amputation, in order to verify the value of distal fingertip replantation over composite grafting, especially in early childhood. Seventeen young children (aged 3 years and 8 months on average), with single-digit fingertip amputations in Tamai zone I were reviewed from 1993–2008. Each amputation was subdivided into three types: distal, middle, and proximal. There were three distal, 13 middle, and one proximal type zone I amputations. All were crush or avulsion injuries. All three distal-type cases were reattached as primary composite grafts with one success. For middle-type cases, the survival rate of primary composite graft without exploration for possible vessels for anastomosis was 57%. On exploration, suitable vessels for anastomosis were found 50% of the time, in which all replantations were succeeded. The remaining cases were reattached as secondary composite grafts, with one success using the pocket method. Consequently, the success rate after exploration was 67%. The only one proximal-type amputation was failed in replantation. For the middle-type zone I amputation in early childhood, replantation has a high success rate if suitable vessels can be found. Therefore, exploration is recommended for amputations at this level with a view to replantation, irrespective of the mechanism of injury.     

Results of flexor tendon tenolysis after replantation in the hand

Thirty-seven replanted digital units and four thumb replantations had a flexor tendon tenolysis at an average of 10 months after replantation. The results were assessed by measuring total active motion, potential active motion, and by the formula of Strickland and associates. The total active motion increased from a mean pretenolysis of 72 degrees to 130 degrees. The potential active motion increased from a mean of 43% to 70% after tenolysis. Both of these improvements were statistically significant (p less than 0.001). The formula of Strickland and associates rated 13 excellent, 11 good, 6 fair, and 11 poor. The thumbs had two fair results and two poor results. Poor results were also seen in crush or avulsion amputations, hands with more than two digits amputated, and those requiring a proximal interphangeal joint capsulotomy. Little difference was found related to the number of arteries or tendons repaired. Complications included tendon rupture and infection. No digits were lost. The results of this study would support flexor tendon tenolysis after replantation of fingers but not replanted thumbs.