Major limb,hand, and digital replantation

Successful replantation of an amputated extremity depends mainly upon the accurate repair of blood vessels, but the final goal must be complete restoration of function. Before a decision to replant is made, the extent of tissue damage, the patient's age and general condition, sex, occupation, and the patient's wishes regarding replantation are evaluated. All tissues that influence survival of the replanted part and its ultimate function must be repaired primarily. An operating microscope should always be used for the vascular and nerve repairs, especially in digital replantation. Good postoperative management is the final key for successful replantation, and includes prevention of thrombosis and adequate rehabilitation. Systemic heparinization is used in digital replantation, but is not used in major limb replantation. Rehabilitation is begun on the first post-operative day, but several reconstructive operations may be necessary on the replanted part to achieve improved function. Between May, 1959 and December, 1977, replantation operations were performed in 218 extremities of 159 patients. Thirteen of 16 major limb replantations and 181 of 204 digital replantations have survived, an overall success rate of 88%. Functional recovery has varied in each individual for several reasons, but most patients are satisfied with the function of their replanted part.

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Résumé Dans les réimplantations de membres ou segments de membres amputés, le succès dépend principalement de la revascularisation, mais le but final doit être la récupération fonctionnelle complète. Avant de décider d'une réimplantation, il faut prendre en considération l'étendue des lésions tissulaires, l'âge du malade, son sexe et son état général, ses occupations et ses souhaits concernant la réimplantation. Tous les tissus qui vont influencer la survie du segment amputé et sa fonction doivent être immédiatement réparés et suturés. Pour les anastomoses vasculaires et nerveuses, il faut toujours travailler sous microscope opératoire, en particulier pour les réimplantations de doigts. Une surveillance et un traitement post-opératoires adéquats sont essentiels: il faut, entre autre, prévenir les thromboses et assurer une excellente rééducation. L'héparinisation est utilisée pour les réimplantations de doigts, mais pas pour les ré implantations de membres. La rééducation doit commencer dès le premier jour postopératoire; mais plusieurs opérations reconstructives peuvent être nécessaires pour atteindre un résultat fonctionnel satisfaisant.Entre Mai, 1959 et Décembre, 1977, nous avons réalisé 218 réimplantations chez 159 patients. Sur 16 réimplantations de membres, 13 ont réussi et sur 204 réimplantations de doigts, 181 sont restées viables, soit au total 88% de succès. Le degré de la récupération fonctionnelle a été variable d'un malade à l'autre, pour des raisons diverses, mais la majorité des opérés sont satisfaits des résultats.

     

Major limb replantation in children

This retrospective study evaluated patients under 18 years of age who underwent major limb replantation between 1976 and 1989 at Louisville Hand Surgery. The age of the 15 patients followed for between 1 and 8.5 years (mean 4.2 years) ranged from 2 to 17 years (mean 9.8). Of amputations, 40% were guillotine, 40% were limited crush-avulsions, 7% were extended crushing, and eight were of an upper extremity and seven of a lower extremity. Average warm/total ischemia times were 4.8/14.8 hr in failures and 1.1/7.5 hours in successful replantation. Overall limb survival was 87%. Among the patients, 93% felt that their replanted limb functioned and looked better than a prosthesis; 87% of patients had a sensory recovery of more than S2+ in the lower extremity or S3 in the upper extremity; and 38% of upper extremity replantation patients had two-point discrimination of less than 15 mm.     

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.     

Transpositional digital replantation

When a functionally important digit is injured as part of a multiple digit injury, transpositional digital replantation is worth considering to preserve greater hand function and to avoid or minimize the necessity for secondary reconstructive procedures. We present two such cases with transpositional digital replantation. The indications for this technique are: 1) multiple digit injury, 2) severe crush injury, 3) the possibility of preserving more and better joints in some fingers, and 4) injury distal to Tamai's zone V (11). The benefits of this procedure are that function can be better with the more completely preserved digits replanted into the most useful positions and of similar lengths. Difficulties are encountered when there are large discrepancies in size of surviving digits, and problems with soft-tissue coverage, tendon repair, a 'step' at the fracture site after bone fixation, and with vessel anastomosis. Use of this procedure can result in preservation of hand function and fewer secondary reconstructive procedures.     

Major upper limb replantation

Major amputations remain a challenge to the replantation surgeon. Proper patient selection, good surgical skills, and cooperation among the patient, surgeon, and rehabilitation team help achieve a better outcome.     

Above elbow limb replantation: functional results

Seven patients with a complete transhumeral limb amputation had their limb replanted. In all seven limbs the mechanism of injury was avulsion, and the ischemic time was relatively prolonged, with a range of 10 to 14 hours. The five patients with surviving limbs achieved useful elbow control. Of these patients, two achieved useful distal function to the wrist and hand and one had a below elbow amputation. All but one patient required multiple secondary operative procedures, with an average of 2.8 procedures for those patients with surviving limbs. We did not encounter any significant life-threatening problems. Less serious complications were encountered in all but three patients during the postoperative period. We suggest that limb replantation at transhumeral levels may be of value for recovery of elbow function in most of these patients. In some instances, this may permit the conversion of an above elbow level amputation to a functional below elbow level. In a few patients, recovery of useful hand function may be achieved.     

Proximal upper limb replantation in children

Proximal upper limb amputation not only leads to serious local disability but carries with it substantial systemic implications. The replantation of an avulsed limb is all too frequently followed by disappointing functional results. In children, however, with secure bony stability, vascular reconstruction and immediate appropriate nerve repair the results of replantation can be most gratifying. Two such cases have been seen at The Hospital for Sick Children and are reported in detail. The late functional results as illustrated make this complex procedure a very worthwhile undertaking.     

Temperature monitoring in digital replantation

Postoperative monitoring of replanted and revascularized digits with skin temperature probes was performed on the 20 patients admitted to the Duke University Medical Center Orthopaedic Replantation Service from April to July, 1977. Using multiple probes, temperatures were recorded for the replanted digit, a control digit on the same hand, and the dressing which represented the ambient temperature. In addition, the following simultaneous clinical inspections were performed on the digits: capillary refill, skin color, turgor, audibility of arterial Doppler tones, and amplitude of pulp pressure tracing. Temperatures of the replanted digits were in the range of 26.0 degrees to 35.0 degrees C. Control temperatures remained relatively stable, in the range of 33.0 degrees to 35.0 degrees C. From the authors' experience the patterns of temperature change which signaled changes in perfusion of the replanted digit and possible poor prognosis were (1) the temperature of the replanted digit dropping more than 2.5 degrees C while the control temperature stayed constant; (2) the temperature of the replanted digit dropping below 30.0 degrees C for longer than 1 hour; and (3) the control temperature dropping below 30.0 degrees C with no correctable cause found.     

Skeletal fixation in digital replantation

Although the primary objective of replantation is revascularization and ultimately viability of the amputated digit(s), skeletal stabilization is an important cornerstone of the composite repair and reconstructive process. If performed rapidly and securely, anatomic (or near anatomic) fracture reduction and fixation may contribute profoundly to the protection of the revascularization and the repair or reconstruction of nerves, tendons, and integument; reliable fracture healing; functional restoration; and final outcome. Conversely, less than anatomic (or near anatomic) reduction or unreliable and insecure fixation may deter successful early revascularization and, later, good function. This article reviews the various methods of fracture stabilization that may be employed, and their advantages and disadvantages. We believe that anatomic (or near anatomic) fracture reduction, reliable and stable fracture fixation, minimal additional dissection, and early active range-of-motion exercises will have a substantial effect on both viability and functional outcome in digital replantation.     

Venous flaps in digital revascularization and replantation

This is a report on 15 patients who underwent replantation/revascularization of a single digit with a substantial dorsal soft tissue defect. The dorsal defect was covered with a venous flap, a free flap that has only venous inflow and outflow. Postoperatively, the venous flaps were warm, pink, and appeared to exhibit a blanch and refill phenomenon, clinically resembling capillary filling. The flaps from the dorsal aspect of an uninjured digit had a survival rate of 100 percent, with no partial necrosis, while the flaps from a forearm or dorsal foot donor site failed. The advantages of using venous free flaps are twofold. Not only does this technique provide for venous drainage, but it also provides flap coverage and avoids complications, such as vessel occlusion or hematoma formation, associated with skin grafting over a venous anastomosis, with subsequent loss of the skin graft.