- Email: [email protected]
Distal Finger Replantation
SURGICAL TECHNIQUE
Distal Finger Replantation Luis R. Scheker, MD, Giles W. Becker, MB BChir
ISTORICALLY, RECONSTRUCTION OF the fingertip distal to the flexor tendon insertion by replantation has been controversial. It is technically challenging surgery with a high chance of failure, yet it can avoid painful neuroma formation or unacceptable cosmesis. In the 1960s, after Kleinert and Kasdan1 reported the first digital artery repair, Komatsu and Tamai2 replanted the first thumb, and the work was completed at the Sixth Shanghai People’s Hospital,3 replantation of amputated digits became a reality. Since then, microsurgery has evolved at a rapid pace; however, the need for tip reattachment has remained contentious. Reconstruction can be achieved with myriad small flaps, but no reconstruction is as good as the part itself: guillotine amputation of the fingertip in which there is little tissue damage and where vessels and nerves can be connected without grafts allows restoration of cosmesis and function to the injured hand. Modern perioperative management techniques also mean that this procedure can usually be performed as outpatient surgery, often under local anesthetic block.
H
INDICATIONS AND CONTRAINDICATIONS There are no absolute indications for very distal tip replantation, but we believe it should be considered for From the Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY. Received for publication June 29, 2010; accepted in revised form December 17, 2010. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Correspondingauthor:LuisR.Scheker,MD,ChristineM.KleinertInstitute,225AbrahamFlexner Way, Suite 850, Louisville, KY 40202; e-mail: [email protected]. 0363-5023/11/36A03-0028$36.00/0 doi:10.1016/j.jhsa.2010.12.017
all digits in children and young women, and those for whom full restoration of length is professionally advantageous, such as musicians. The procedure is contraindicated in injuries where there is considerable tissue damage by crushing or contamination, peripheral vascular disease, or systemic conditions with associated vascular problems such as diabetes. Manual workers who require an early return to function should also not be considered. SURGICAL ANATOMY The vascular anatomy of the digits is well described4,5 (Fig. 1). The thumb, index, and long fingers have a dominant ulnar digital artery; in the ring and small fingers it is the radial digital artery. The 2 digital arteries anastomose as palmar arches 3 times: at the level of the C1 and C2 cruciate pulleys, and finally just distal to the flexor digitorum profundus tendon insertion as the rounded distal transverse palmar arch (DTPA); 3 or more vessels then radiate longitudinally out from the DTPA to supply the pulp, with the central vessel usually having the largest caliber. These then turn back dorsally, to anastomose with the dorsal proximal matrix arch, which supplies the nail plate germinal matrix; this arch has its arterial origins just before the DTPA. Branches from the distal radiating vessels also pass dorsally to anastomose and supply the nailbed via the middle and distal matrix arches. As the digital arteries divide at the level of the DTPA, they routinely decrease in size from approximately 0.8 mm to as small as 0.3 mm in the radiating branches. Venous anatomy is unfortunately rather more variable (Fig. 2). At the level of the eponychium, 63% of fingers might have a vein 0.8 mm or larger, but the
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 521
Surgical Technique
Reconstruction of the fingertip distal to the flexor tendon insertion by replantation remains controversial and technically challenging, but the anatomy of the fingertip has been well described and provides help in surgical planning. The open-book surgical technique is described with potential complications and is illustrated with clinical cases. (J Hand Surg 2011;36A:521–528. Copyright © 2011 by the American Society for Surgery of the Hand. All rights reserved.) Key words Finger replantation, finger revascularization, hand injury.
522
DISTAL FINGER REPLANTATION
Surgical Technique FIGURE 1: Arterial supply to the finger. Used with permission of the Christine M. Kleinert Institute.
FIGURE 2: Venous drainage of the finger. Used with permission of the Christine M. Kleinert Institute.
location of these veins is unpredictable. Searching laterally for the commissural veins provides the greatest likelihood of success, at all levels of distal tip amputation, with an equal mix of vessels 0.5 mm or larger and 0.4 mm or smaller. Restoration of arterial flow can help highlight the position of suitable veins. These may be volar or dorsal.
The finger pulp has a true vascular plexus with a large network of capillaries joining the dorsal venous system, permitting rapid shunting of blood flow to control digital temperature; despite the digital blanching and hypoperfusion caused by active hyperextension of the fingers, 97% of the blood flow through the pulp persists. If the tip is not replanted after injury, loss of
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DISTAL FINGER REPLANTATION
FIGURE 3: Method of raising volar skin flap to access subcutaneous veins. A The dorsal skin edges are anatomically opposed and a retrograde wire is inserted. B The finger is turned over, and triangular flaps are raised from the volar aspect. C Neurovascular repair. D Wound closure.
this plexus means that the ability to thermoregulate the entire digit is lost. The digital nerves trifurcate after the distal interphalangeal joint crease in 78% of fingers and 60% of thumbs,6 into proximal dorsal and distal medial and lateral ungual branches.7 There is then a large degree of crossover of the territories supplied, accounting for the return to sensibility of areas distal to injury without nerve repair. SURGICAL TECHNIQUE The best results will always be achieved in a clean amputation with limited dissection. The patient should be kept warm, regional anesthesia should be administered, and a tourniquet should be applied but not initially inflated. The wounds should be debrided as little as possible. If the amputation is through the distal
interphalangeal joint, primary arthrodesis of the joint should be considered. The first step is to identify the arterial inflow from its pulsations and apply a microvascular clamp to suitable vessels, highlighting them for identification as the tourniquet is then inflated, before the anastomoses are performed. The distal portion of each vessel is located by opposite proximity to the clamped vessels. A fine K-wire is then passed anterograde through the bone of the amputated part (or a hypodermic needle retrograde in children). Suture of the palmar skin then follows, using the available fingerprint to line up the 2 sides anatomically. The divided structures are then repaired according to the open-book technique of Morrison and McCombe.8 As the palmar skin is closed, the ends of the palmar arteries and nerves
JHS 䉬 Vol A, March
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Surgical Technique
FIGURE 4: Patient 1: Anteroposterior radiograph of affected thumb showing oblique avulsion through the distal phalanx.
FIGURE 6: Patient 1: K-wire is passed through the amputated part.
FIGURE 5: Patient 1: Arterial inflow located and marked with micro clamp.
FIGURE 7: Patient 1: Immediately postreplantation (i).
approximate. Under high-power microscope magnification, the vessels can be repaired using 11-0 suture with a 50-m needle; anastomosis commences first with the back wall of the vessel. The vascular clamp is removed to allow more room to work after tying the first knot. This knot serves to identify vessels; epineural approximating sutures can then be applied to the nerves. Lateral or dorsal veins may then be repaired as the dorsal wound
edges come into approximation. If the vessel or nerve ends are not easily visible, a small amount of dissection can be performed; backflow in the veins after arterial repair helps to highlight their position. Identification of suitable venous outflow can be aided by raising triangular skin flaps as fullthickness skin grafts to avoid damage to the subcutaneous veins9 (Fig. 3). As the anastomoses progress dorsally, the tension is removed by adding skin sutures. Finally, the K-wire is passed
JHS 䉬 Vol A, March
FIGURE 8: Patient 1: Immediately postreplantation (ii).
FIGURE 10: Patient 1: Final result (ii).
FIGURE 9: Patient 1: Final result (i).
retrograde into the proximal bone end, ensuring a firm grip on the replanted part to prevent spinning as the wire turns. The skin sutures should be loose to prevent further vascular compromise, and they should be well spaced. If the digital arteries lie directly in contact with the undersurface of the phalanx, it may be difficult to approach their repair via this approach from the dorsum. In this case, the hand should be inverted and the repairs performed
FIGURE 11: Patient 2: Injury with amputated part.
sequentially from dorsal to volar. This overall technique is the same in children, even when the amputation is through the physis of the distal phalanx.
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FIGURE 12: Patient 2: Arterial inflow is located and marked with a micro clamp.
Surgical Technique
FIGURE 14: Patient 2: Final result (i).
FIGURE 13: Patient 2: 2 weeks postsurgery.
Before tourniquet deflation and before blood is allowed to flow back into the tip, a bolus of intravenous low-molecular-weight dextran with heparin should be administered, to decrease the risk of thrombosis. If no suitable distal arteries are found, arteriovenous anastomotic shunting can provide enough flow to allow survival, but results are mixed.10,11 If there are no suitable veins for anastomosis, a number of techniques may be employed to prevent venous congestion. Most simply, shaving the nailbed or the skin overlying the pulp can be combined with heparin-soaked pledgets to ensure continued drainage. Some advocate a fish-mouth incision in
FIGURE 15: Patient 2: Final result (ii).
the pulp, but we do not favor this technique because of the deep damage it causes to the replanted tip. The Hirudo medicinalis leech may also be used; it is able to remove 5 times its own body weight of blood in 15 minutes before detaching. If we have to employ one of these methods, we admit the patient and prescribe a continuous infusion of intravenous low-molecular-weight dextran with heparin. Postoperatively, we wrap the digit in a bulky protective dressing, prescribe the patient a small dose of
JHS 䉬 Vol A, March
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FIGURE 18: Patient 3: During replantation. Note dorsal to volar repair undertaken because of immediate proximity of arteries to volar aspect of the phalanx.
FIGURE 16: Patient 3: Original injury.
FIGURE 17: Patient 3: x-ray of amputated fingertips. Note severe crush to the ring tip (on the right) precluding replantation.
aspirin, and advise him or her to avoid tobacco-based products and caffeine. CLINICAL CASES 1. A 15-year-old girl who caught her dominant right
thumb in a meat slicer on her first day of a new summer job. She arrived in the emergency room within an hour of the accident (Figs. 4 –9). 2. A 32-year-old woman who caught the ulnar border of her dominant ring digit tip in a punch press. There was minimal crush injury (Figs. 10 –15). 3. A 35-year-old man who crushed his nondominant long and ring finger tips in a molding press. He underwent replantation of the long fingertip and V-Y advancement flap to the ring, because the tip was too damaged (Figs. 16 –20).
FIGURE 19: Patient 3: 2 weeks after surgery.
COMPLICATIONS Possible adverse events after tip replantation differ little from more proximal replants. Arterial or venous occlusion may occur, but reexploration in this setting is usually futile. The tip therefore becomes a biological dressing and the patient is in the same position as before replantation, facing possible re-
JHS 䉬 Vol A, March
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DISTAL FINGER REPLANTATION
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DISTAL FINGER REPLANTATION
painful neuroma formation and maintains the length of the digit; for a musician, this may even prevent a premature end of career. The cosmetic result is better than any reconstruction achievable using flaps. No flap is better than the original part, and with modern perioperative techniques, this surgery can safely and comfortably be performed on an outpatient day-case basis. REFERENCES
Surgical Technique
FIGURE 20: Patient 3: Final result.
vision amputation. The no-reflow phenomenon is less likely to be an issue, because the bulk of tissue rendered ischemic by the injury is relatively small. Infection risk is diminished by the routine administration of antibiotic prophylaxis, with specific cover for the leeches if used. Fingertip replantation reduces the chance of
1. Kleinert HE, Kasdan ML. Anastamosis of digital vessels. J Ky Med Assoc 1965;63:106 –108. 2. Komatsu S, Tamai S. Successful replantation of a completely cut-off thumb. Plast Reconstr Surg 1968;42:374 –377. 3. Chen CW, Chien YC, Pao YS, Lin CT. Reattachment of traumatic amputations, a summing up of experiences. Chin Med J (Engl) 1967;1:392-401. 4. Strauch B, de Moura W. Arterial system of the fingers. J Hand Surg 1990;15A:148 –154. 5. Smith DO, Oura C, Kimura C, Toshimori K. The distal venous anatomy of the finger. J Hand Surg 1991;16A:303–307. 6. Zenn MR, Hoffman L, Latrenta G, Hotchkiss R. Variations in digital nerve anatomy. J Hand Surg 1992;17A:1033–1036. 7. Johnson RK, Shrewsbury MM. Neural pattern in the human pollical distal phalanx. Clin Anat. 2005;18:428 – 433. 8. Morrison WA, McCombe D. Digital replantation. Hand Clin 2007; 23:1–12. 9. Tsai TM, McCabe SJ, Maki Y. A technique for replantation of the finger tip. Microsurgery 1989;10:1– 4. 10. Fukui A, Maeda M, Inada Y, Tamai S, Sempuku T. Arteriovenous shunt in digit replantation. J Hand Surg 1990;15A:160 –165. 11. Koshima I, Soeda S, Moriguchi T, Higaki H, Miyakawa S, Yamasaki M. The use of arteriovenous anastomosis for replantation of the distal phalanx of the fingers. Plast Reconstr Surg 1992;89:710 –714.
JHS 䉬 Vol A, March
Distal Finger Replantation Luis R. Scheker, MD, Giles W. Becker, MB BChir
ISTORICALLY, RECONSTRUCTION OF the fingertip distal to the flexor tendon insertion by replantation has been controversial. It is technically challenging surgery with a high chance of failure, yet it can avoid painful neuroma formation or unacceptable cosmesis. In the 1960s, after Kleinert and Kasdan1 reported the first digital artery repair, Komatsu and Tamai2 replanted the first thumb, and the work was completed at the Sixth Shanghai People’s Hospital,3 replantation of amputated digits became a reality. Since then, microsurgery has evolved at a rapid pace; however, the need for tip reattachment has remained contentious. Reconstruction can be achieved with myriad small flaps, but no reconstruction is as good as the part itself: guillotine amputation of the fingertip in which there is little tissue damage and where vessels and nerves can be connected without grafts allows restoration of cosmesis and function to the injured hand. Modern perioperative management techniques also mean that this procedure can usually be performed as outpatient surgery, often under local anesthetic block.
H
INDICATIONS AND CONTRAINDICATIONS There are no absolute indications for very distal tip replantation, but we believe it should be considered for From the Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY. Received for publication June 29, 2010; accepted in revised form December 17, 2010. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Correspondingauthor:LuisR.Scheker,MD,ChristineM.KleinertInstitute,225AbrahamFlexner Way, Suite 850, Louisville, KY 40202; e-mail: [email protected]. 0363-5023/11/36A03-0028$36.00/0 doi:10.1016/j.jhsa.2010.12.017
all digits in children and young women, and those for whom full restoration of length is professionally advantageous, such as musicians. The procedure is contraindicated in injuries where there is considerable tissue damage by crushing or contamination, peripheral vascular disease, or systemic conditions with associated vascular problems such as diabetes. Manual workers who require an early return to function should also not be considered. SURGICAL ANATOMY The vascular anatomy of the digits is well described4,5 (Fig. 1). The thumb, index, and long fingers have a dominant ulnar digital artery; in the ring and small fingers it is the radial digital artery. The 2 digital arteries anastomose as palmar arches 3 times: at the level of the C1 and C2 cruciate pulleys, and finally just distal to the flexor digitorum profundus tendon insertion as the rounded distal transverse palmar arch (DTPA); 3 or more vessels then radiate longitudinally out from the DTPA to supply the pulp, with the central vessel usually having the largest caliber. These then turn back dorsally, to anastomose with the dorsal proximal matrix arch, which supplies the nail plate germinal matrix; this arch has its arterial origins just before the DTPA. Branches from the distal radiating vessels also pass dorsally to anastomose and supply the nailbed via the middle and distal matrix arches. As the digital arteries divide at the level of the DTPA, they routinely decrease in size from approximately 0.8 mm to as small as 0.3 mm in the radiating branches. Venous anatomy is unfortunately rather more variable (Fig. 2). At the level of the eponychium, 63% of fingers might have a vein 0.8 mm or larger, but the
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 521
Surgical Technique
Reconstruction of the fingertip distal to the flexor tendon insertion by replantation remains controversial and technically challenging, but the anatomy of the fingertip has been well described and provides help in surgical planning. The open-book surgical technique is described with potential complications and is illustrated with clinical cases. (J Hand Surg 2011;36A:521–528. Copyright © 2011 by the American Society for Surgery of the Hand. All rights reserved.) Key words Finger replantation, finger revascularization, hand injury.
522
DISTAL FINGER REPLANTATION
Surgical Technique FIGURE 1: Arterial supply to the finger. Used with permission of the Christine M. Kleinert Institute.
FIGURE 2: Venous drainage of the finger. Used with permission of the Christine M. Kleinert Institute.
location of these veins is unpredictable. Searching laterally for the commissural veins provides the greatest likelihood of success, at all levels of distal tip amputation, with an equal mix of vessels 0.5 mm or larger and 0.4 mm or smaller. Restoration of arterial flow can help highlight the position of suitable veins. These may be volar or dorsal.
The finger pulp has a true vascular plexus with a large network of capillaries joining the dorsal venous system, permitting rapid shunting of blood flow to control digital temperature; despite the digital blanching and hypoperfusion caused by active hyperextension of the fingers, 97% of the blood flow through the pulp persists. If the tip is not replanted after injury, loss of
JHS 䉬 Vol A, March
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DISTAL FINGER REPLANTATION
FIGURE 3: Method of raising volar skin flap to access subcutaneous veins. A The dorsal skin edges are anatomically opposed and a retrograde wire is inserted. B The finger is turned over, and triangular flaps are raised from the volar aspect. C Neurovascular repair. D Wound closure.
this plexus means that the ability to thermoregulate the entire digit is lost. The digital nerves trifurcate after the distal interphalangeal joint crease in 78% of fingers and 60% of thumbs,6 into proximal dorsal and distal medial and lateral ungual branches.7 There is then a large degree of crossover of the territories supplied, accounting for the return to sensibility of areas distal to injury without nerve repair. SURGICAL TECHNIQUE The best results will always be achieved in a clean amputation with limited dissection. The patient should be kept warm, regional anesthesia should be administered, and a tourniquet should be applied but not initially inflated. The wounds should be debrided as little as possible. If the amputation is through the distal
interphalangeal joint, primary arthrodesis of the joint should be considered. The first step is to identify the arterial inflow from its pulsations and apply a microvascular clamp to suitable vessels, highlighting them for identification as the tourniquet is then inflated, before the anastomoses are performed. The distal portion of each vessel is located by opposite proximity to the clamped vessels. A fine K-wire is then passed anterograde through the bone of the amputated part (or a hypodermic needle retrograde in children). Suture of the palmar skin then follows, using the available fingerprint to line up the 2 sides anatomically. The divided structures are then repaired according to the open-book technique of Morrison and McCombe.8 As the palmar skin is closed, the ends of the palmar arteries and nerves
JHS 䉬 Vol A, March
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Surgical Technique
FIGURE 4: Patient 1: Anteroposterior radiograph of affected thumb showing oblique avulsion through the distal phalanx.
FIGURE 6: Patient 1: K-wire is passed through the amputated part.
FIGURE 5: Patient 1: Arterial inflow located and marked with micro clamp.
FIGURE 7: Patient 1: Immediately postreplantation (i).
approximate. Under high-power microscope magnification, the vessels can be repaired using 11-0 suture with a 50-m needle; anastomosis commences first with the back wall of the vessel. The vascular clamp is removed to allow more room to work after tying the first knot. This knot serves to identify vessels; epineural approximating sutures can then be applied to the nerves. Lateral or dorsal veins may then be repaired as the dorsal wound
edges come into approximation. If the vessel or nerve ends are not easily visible, a small amount of dissection can be performed; backflow in the veins after arterial repair helps to highlight their position. Identification of suitable venous outflow can be aided by raising triangular skin flaps as fullthickness skin grafts to avoid damage to the subcutaneous veins9 (Fig. 3). As the anastomoses progress dorsally, the tension is removed by adding skin sutures. Finally, the K-wire is passed
JHS 䉬 Vol A, March
FIGURE 8: Patient 1: Immediately postreplantation (ii).
FIGURE 10: Patient 1: Final result (ii).
FIGURE 9: Patient 1: Final result (i).
retrograde into the proximal bone end, ensuring a firm grip on the replanted part to prevent spinning as the wire turns. The skin sutures should be loose to prevent further vascular compromise, and they should be well spaced. If the digital arteries lie directly in contact with the undersurface of the phalanx, it may be difficult to approach their repair via this approach from the dorsum. In this case, the hand should be inverted and the repairs performed
FIGURE 11: Patient 2: Injury with amputated part.
sequentially from dorsal to volar. This overall technique is the same in children, even when the amputation is through the physis of the distal phalanx.
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FIGURE 12: Patient 2: Arterial inflow is located and marked with a micro clamp.
Surgical Technique
FIGURE 14: Patient 2: Final result (i).
FIGURE 13: Patient 2: 2 weeks postsurgery.
Before tourniquet deflation and before blood is allowed to flow back into the tip, a bolus of intravenous low-molecular-weight dextran with heparin should be administered, to decrease the risk of thrombosis. If no suitable distal arteries are found, arteriovenous anastomotic shunting can provide enough flow to allow survival, but results are mixed.10,11 If there are no suitable veins for anastomosis, a number of techniques may be employed to prevent venous congestion. Most simply, shaving the nailbed or the skin overlying the pulp can be combined with heparin-soaked pledgets to ensure continued drainage. Some advocate a fish-mouth incision in
FIGURE 15: Patient 2: Final result (ii).
the pulp, but we do not favor this technique because of the deep damage it causes to the replanted tip. The Hirudo medicinalis leech may also be used; it is able to remove 5 times its own body weight of blood in 15 minutes before detaching. If we have to employ one of these methods, we admit the patient and prescribe a continuous infusion of intravenous low-molecular-weight dextran with heparin. Postoperatively, we wrap the digit in a bulky protective dressing, prescribe the patient a small dose of
JHS 䉬 Vol A, March
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FIGURE 18: Patient 3: During replantation. Note dorsal to volar repair undertaken because of immediate proximity of arteries to volar aspect of the phalanx.
FIGURE 16: Patient 3: Original injury.
FIGURE 17: Patient 3: x-ray of amputated fingertips. Note severe crush to the ring tip (on the right) precluding replantation.
aspirin, and advise him or her to avoid tobacco-based products and caffeine. CLINICAL CASES 1. A 15-year-old girl who caught her dominant right
thumb in a meat slicer on her first day of a new summer job. She arrived in the emergency room within an hour of the accident (Figs. 4 –9). 2. A 32-year-old woman who caught the ulnar border of her dominant ring digit tip in a punch press. There was minimal crush injury (Figs. 10 –15). 3. A 35-year-old man who crushed his nondominant long and ring finger tips in a molding press. He underwent replantation of the long fingertip and V-Y advancement flap to the ring, because the tip was too damaged (Figs. 16 –20).
FIGURE 19: Patient 3: 2 weeks after surgery.
COMPLICATIONS Possible adverse events after tip replantation differ little from more proximal replants. Arterial or venous occlusion may occur, but reexploration in this setting is usually futile. The tip therefore becomes a biological dressing and the patient is in the same position as before replantation, facing possible re-
JHS 䉬 Vol A, March
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DISTAL FINGER REPLANTATION
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DISTAL FINGER REPLANTATION
painful neuroma formation and maintains the length of the digit; for a musician, this may even prevent a premature end of career. The cosmetic result is better than any reconstruction achievable using flaps. No flap is better than the original part, and with modern perioperative techniques, this surgery can safely and comfortably be performed on an outpatient day-case basis. REFERENCES
Surgical Technique
FIGURE 20: Patient 3: Final result.
vision amputation. The no-reflow phenomenon is less likely to be an issue, because the bulk of tissue rendered ischemic by the injury is relatively small. Infection risk is diminished by the routine administration of antibiotic prophylaxis, with specific cover for the leeches if used. Fingertip replantation reduces the chance of
1. Kleinert HE, Kasdan ML. Anastamosis of digital vessels. J Ky Med Assoc 1965;63:106 –108. 2. Komatsu S, Tamai S. Successful replantation of a completely cut-off thumb. Plast Reconstr Surg 1968;42:374 –377. 3. Chen CW, Chien YC, Pao YS, Lin CT. Reattachment of traumatic amputations, a summing up of experiences. Chin Med J (Engl) 1967;1:392-401. 4. Strauch B, de Moura W. Arterial system of the fingers. J Hand Surg 1990;15A:148 –154. 5. Smith DO, Oura C, Kimura C, Toshimori K. The distal venous anatomy of the finger. J Hand Surg 1991;16A:303–307. 6. Zenn MR, Hoffman L, Latrenta G, Hotchkiss R. Variations in digital nerve anatomy. J Hand Surg 1992;17A:1033–1036. 7. Johnson RK, Shrewsbury MM. Neural pattern in the human pollical distal phalanx. Clin Anat. 2005;18:428 – 433. 8. Morrison WA, McCombe D. Digital replantation. Hand Clin 2007; 23:1–12. 9. Tsai TM, McCabe SJ, Maki Y. A technique for replantation of the finger tip. Microsurgery 1989;10:1– 4. 10. Fukui A, Maeda M, Inada Y, Tamai S, Sempuku T. Arteriovenous shunt in digit replantation. J Hand Surg 1990;15A:160 –165. 11. Koshima I, Soeda S, Moriguchi T, Higaki H, Miyakawa S, Yamasaki M. The use of arteriovenous anastomosis for replantation of the distal phalanx of the fingers. Plast Reconstr Surg 1992;89:710 –714.
JHS 䉬 Vol A, March