INDICATIONS AND SELECTION FOR DIGITAL AMPUTATION AND REPLANTATION

INVITED REVIEW ARTICLE

INDICATIONS AND SELECTION FOR DIGITAL AMPUTATION AND REPLANTATION P. N. SOUCACOS From the Department of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina, Greece

Even though replantation surgery has now become a routine procedure, it remains delicate and demanding surgery, requiring adequate training and expertise in microsurgical techniques. Welldefined 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. Journal of Hand Surgery (British and European Volume, 2001) 26B: 6: 572–581

INTRODUCTION

SELECTION CRITERIA Three main types of digital amputations are recognized, based on the viability of the digit: including complete amputations, incomplete non-viable amputations, and incomplete viable amputations. Amputations in which both neurovascular bundles and all or most of the venous network system are severed or severely damaged are incomplete non-viable digital amputations. Although the distal segment is connected to the proximal stump by either an isthmus of skin, or a small segment of tendon or nerve, these are not capable of maintaining the viability of the distal part. In incomplete viable amputations, some arterial blood supply and venous outflow from the digit are present. Nevertheless, these injuries represent a grey zone which needs to be assessed under the operating microscope to determine whether both the arterial blood supply and venous outflow of the digit are adequately served. While we have found the survival rate is statistically higher in patients with incomplete nonviable amputations (89%) compared to those with complete amputations (81%), the patient’s ability to use the replanted digit was about the same in both groups (Soucacos et al., 1995c).

The advent of the operating microscope along with micro-instruments and micro-sutures, made possible successful anastomoses of digital arteries in incomplete digital amputations (Kleinert et al., 1963; Lendvay, 1968). It was not until 1965 that the first digital replantation of a completely amputated thumb using microvascular techniques was achieved by Komatsu and Tamai (1968). Since then, numerous revascularization and replantation procedures for amputated digits have taken place (Buncke et al., 1981; Macleod et al., 1978; Merle et al., 1991; Morrison et al., 1977; Soucacos, 1995a; Urbaniak, 1987). The results have been assessed according to the type of amputation (Kleinert et al., 1977; Soucacos et al., 1995a; Zong-Wei, 1981), the severity of the injury (Beris et al., 1994; Stevanovic et al., 1991; Vlastou and Earle, 1986), the number of amputated digits (Soucacos et al., 1994b, 1994c) and the various technique applied (Beris et al., 1992; Brown and Wood, 1990; Meuli et al., 1978; Soucacos et al., 1994c). The initial tendency to replant virtually every amputated part eventually gave way to attempts to define strict selection criteria and optimize the functional results. Today, the major concern is not ‘‘how to replant an amputated part’’, but rather ‘‘how to make it functional’’ (Leung, 1985). In this regard, replantation without sensation and function is no longer considered acceptable (Shaw and Hidalgo, 1987). Fundamental to the success in replantation of a digit is not only a solid microsurgical technique for vascular microanastomosis, nerve coaptation and tendon repair, but also a clear understanding of the selection criteria (Midalgo et al., 1987).

TYPE OF AMPUTATION Thumb Since the thumb provides more than 40% of the entire hand’s function, it is indisputably given first priority for replantation (Chow et al., 1979; Earle and Watson 1984; Merle et al., 1991; Soucacos et al., 1994b, 1995a). 572

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Fig 1 Replantation of the thumb always has prime priority. (a) Preoperative view of complete amputation of the right thumb of a 28 years old patient. (b) Nine months postoperatively showing successful replantation with good function and cosmetic appearance.

Moreover, a successfully replanted thumb always produces results which are far better than any other reconstructive procedure or prosthetic device. Crucial factors for a functional thumb replantation are length and sensitivity. Compared to complete amputations of the thumb, incomplete non-viable amputations of the thumb are associated with a statistically higher rate of survival (86% versus 78%) and better sensibility (Soucacos et al., 1995a), while motion at the interphalangeal joint did not differ. The necessity for replantation or reconstruction in bilateral thumb amputations is based not only on the severity of the wound itself, which functionally incapacitates the hand, but to the fact that since both hands are critically impaired the patient is prohibited from performing fundamental daily tasks which involve pinching and grasping with the hands (Soucacos et al., 1994b). Thus, the indications for bilateral thumb replantations are even greater than for single amputations of the thumb (Fig 1).

Single digit There are three major indications for single digit replantation. The first is when the level of

the amputation is distal to the insertion of the flexor digitorum superficialis. In a successful replantation, the digit immediately becomes functional as flexion of the middle phalanx by the intact superficialis tendon is possible (Soucacos et al., 1995d; Urbaniak, 1985; Fig 2). Amputations at the level of the distal phalanx are also indications (Foucher et al., 1981; Malizos et al., 1994; Merle et al., 1991; Yomano, 1985). Here replantation is usually achieved by anastomosis of one artery, while venous drainage can be provided by provoked bleeding or the application of leeches (Soucacos et al., 1994a; Fig 3). A third indication for single digit replantation is ring avulsion injuries Type II or IIIa. These are defined as combined open hand injuries involving both the dorsal and palmar skin and blood supply (arterial inflow and venous return) in an isolated finger (Beris et al., 1994; Soucacos and Beris, 1998). In this type of injury, the flexor digitorum superficialis tendon remains intact. If the replantation procedure is successful, the digit immediately becomes functional as flexion of the middle phalanx is possible. Since the outcome is almost always good, they present a strong indication for replantation (Fig 4).

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Fig 2 One of the three main indications for replantation of a single digit (a) Preoperative view showing complete amputation of the left index finger, slightly distal to the insertion of the flexor digitorum superficialis tendon and (b) the distal amputated part. (c) Postoperative view showing good flexion of the replanted digit.

Replantation of a single digit which is amputated at the level of the proximal phalanx or at the proximal interphalangeal joint, particularly in avulsion or crush injuries, is contra-indicated. This is because the replanted finger hardly ever regains useful function, even if the patient later undergoes multiple, mostly unsuccessful, reconstructive procedures. However, a relative indication for the replantation of a single digit is found in carefully identified patients who

have highly demanding professions, such as musicians (Fig 5). Multiple digits Amputations of more than one digit have a high priority for replantation. The more digits that can be replanted, the better the functional result. Thus, in cases where the amputated segments are identified as being too severely

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Fig 3 The second of the three main indications for replantation of a single digit. (a) Preoperative view showing a complete amputation at the level of the distal phalanx of the thumb. (b) Postoperative view of the successful replantation. (Only one digital artery was anastomosed and the venous return was accommodated by leeches and provoked bleeding using heparin gauzes.)

mutilated and damaged, efforts are geared towards replanting the least damaged amputated part to the most useful stump (transpositional replantation). When not all of the digits can be replanted and the thumb remains intact, the aim is to restore the width of the palm by replanting or transposing digits to the ulnar side. By this transpositional procedure, the power grasp of the hand is augmented, while light pinch is maintained (Soucacos et al., 1994c).

Transpositional Microsurgery Transpositional digital microsurgery refers to the transposition and replantation of any amputated digit to another stump, so that it plays a more significant role in the function of the hand. Five major indications for transpositional digital microsurgery have been identified (Soucacos et al., 1994c). Multiple digit amputations including the thumb: When the thumb is not replantable, either because it is too short or is too extensively damaged, the least damaged digit is replanted in the place of the mutilated thumb.

When successful, the patient’s hand is usually both functionally and cosmetically acceptable (Fig 6). Bilateral thumb amputations: In patients who have sustained amputation of both thumbs and in whom the thumb of the dominant hand is severely crushed and damaged, the less damaged thumb of the non-dominant hand is transposed to the thumb stump of the dominant hand. This maintains dexterity in the dominant hand. If, in addition, the patient has sustained multiple finger amputations, the least damaged finger is transposed to the stump of the thumb if one or both of the thumbs are badly damaged. Bilateral, symmetrical amputations: If the thumb is intact, the replantation effort is directed towards increasing the dexterity of the dominant hand by transposing digits over from the non-dominant hand. Multiple amputations with the thumb intact: Patients with multiple digital amputations in which the thumb remains intact are included in this group. In these patients, an effort is made to replant the digits towards the ulnar side of the hand, so as to preserve the width of the palm and thus increase the power grasp of the hand.

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Fig 4 The third of the three main indications for replantation of a single digit. (a) Preoperative view showing a ring avulsion injury of the ring finger, Type II. (b and c) Dorsal and palmar postoperative views showing successful revascularization which was achieved with the anastomosis of one digital artery and two dorsal veins. Note the ring constriction scar remaining at the level of the degloving injury.

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Fig 5 Typical absolute contraindications for replantation of a digit. (a) Amputation of the index finger at the proximal phalanx. (b) Intra-articular avulsion amputation of the long finger at the PIP joint. (c) Severly crushed and avulsed injuries of the distal amputated parts which make them unsuitable for replantion.

Amputation of all five digits: The aim is two-fold. First, the goal is to replant and create a functional thumb. Second, an effort is made to transpose the digits ulnarly, thus, preserving the width of the palm, as well as the power grip. Transposition microsurgery has a clear place in the treatment of patients in whom the thumb is not replantable, as well as in patients with multiple digital amputations in whom the width of the palm and the power grasp of the hand need to be preserved. The fact that arterial and venous anastomoses can be done

without tension and on a relatively normal intima are advantages of this procedure, which avoids the need for time-consuming interpositioned microvenous grafts.

Mid-palm amputations Mid-palm amputations, whether or not they include the thumb, are ideal candidates for replantation and constitute an absolute indication. If replantation is successful, with adequate restoration of both power

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Fig 6 Every effort is made to replant as many digits as possible in multiple digit amputations. In cases with severe mutilation of some digits, the least damaged digit can be transposed to the most useful stumps using transpositional microsurgery. (a) Preoperative view showing amputation of the thumb and index finger: there was a severe crushing injury of the thumb which made it unreplantable. (b) Postoperative view showing successful transposition of the less damaged index finger to the stump of the thumb with excellent functional results.

grasp and light pinch, the hand achieves a functional ability which is superior to any type of prosthetic device. The incidence of successful replantation is significantly higher for amputations at the level of the superficial or

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Fig 7 (a) Preoperative view showing a midpalm amputation at the level of the superficial and deep palmar arch. (b) Postoperative view showing successful replantation.

deep palmar arch, compared with those at the level of the common digital arteries (Soucacos, 1995a; Fig 7).

GENERAL INDICATIONS In addition to selection criteria related to the type, level and severity of the amputation, other general factors related to the patient should be considered before

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replantation is attempted. These include age, mechanism of injury, ischaemia, general health, predicted rehabilitation, and vocation. In children, an attempt should be made to replant almost any amputated digit. In contrast, poor nerve regeneration, joint stiffness, strength and coordination pose problems for good functional outcome in the elderly. Clean-cut ‘‘guillotine’’ type amputations are good candidates for replantation. Severely crushed or avulsed digits have extensive vascular, nerve and soft tissue damage and the outcome is usually poor. Segmental injuries at multiple levels are usually associated with severe vascular damage, often too extensive to warrant replantation. Ischaemia remains a key factor in determining the success of replantation (Brunelli, 1988). Since digits consist mostly of skin, bone and subcutaneous tissue and contain no muscles, warm ischemia is tolerated for a longer period. After adequate cooling, we have experienced successful replantation after 24 hours and it has been reported after 36 hours. However limbs which contain a high percentage of muscle can tolerate only 4 to 6 hours of ischaemia following amputation. Warm ischaemia or anoxia at 208 to 258C produce irreversible necrotic changes to the muscle and soft tissues. Because digits lack muscle, the time allowed for warm ischaemia is about 8 hours, compared to 6 hours for the upper or lower extremity. By cooling the amputated part to 48C the ischaemia time for digits can be extended to up to 30 hours. The importance of both warm and cold ischemia on the survival of the amputated part and success of the procedure, suggests that amputations occurring in warmer countries or even during the warm seasons should have a lower success rate. If the patient has sustained other major life-threatening injuries at the time of trauma, then replantation of digits may need to be postponed or even cancelled. Certain diseases which can adversely affect peripheral circulation, such as diabetes mellitus, some autoimmune diseases, collagen vascular diseases or atherosclerosis, may contraindicate replantation.

SURGICAL SEQUELAE AND TECHNIQUES IN REPLANTATION Survival depends upon the successful anastomosis of both the digital arteries without tension and on healthy intima, as well as two dorsal veins per patent digital artery. After thorough cleansing and debridement, structures are identified and repair is performed. In most cases, the repair of digits takes the following sequence: (1) tissue debridement; (2) neurovascular identification in the amputated part and stump; (3) bone shortening and stabilization; (4) extensor tendon repair; (5) flexor tendon repair (if it is clean-cut and primary repair can be done); (6) arterial anastomoses;

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(7) venous anastomoses; (8) nerve repair; and (9) softtissue and skin coverage. All structures are repaired primarily, including nerves and tendons unless a large nerve gap is present which necessitates a secondary nerve and tendon grafting procedure. Bone fixation Bone shortening usually proceeds osteosynthesis and vessel anastomosis (Brown and Wood, 1990; Meuli and Meyer, 1978; Touliatos et al., 1995). In general, the procedure entails the careful resection of the bone ends to ensure ease of approximation of the vessels and nerves with minimal stripping of the periosteum. We prefer to remove bone from the amputated part, so that if the replantation fails, length of the stump has not been sacrificed. The amount of bone removed depends upon the level of the amputation (Touliatos et al., 1995). In amputations of the thumb, most of the bone shortening should be done on the amputated part to preserve good bone stock on the stump in case the replantation fails. In amputations through the metacarpophalangeal joint, an attempt should be made to obtain a resection arthroplasty by resection of the metacarpal head, leaving the base of the proximal phalanx with the cartilage intact. If the amputation is through the shaft of the phalanges, we usually remove bone from both ends, while in amputations through the interphalangeal joints, bone is removed from both ends and the joint is arthrodesed. Mini plates with screws, single lag screws, crossed Kirschner wires (K-wires), a combination of intraosseous circlage wires and K-wires, as well as intramedullary K-wires are examples of the materials and techniques suitable for bone fixation (Touliatos et al., 1995). Relatively rapid methods for bone fixation include bone or cement pegs. Alternatively, a screw can be inserted longitudinally into the bone of the the distal part; after which its head is cut off: the remaining shaft is screwed into the proximal stump. We have found that intramedullary K-wires, supplemented by a second wire inserted at the end of the procedure, are the most effective means of digital bone fixation. This technique is both simple and fast, requires minimal bone exposure, and provides the surgeon with the possibility of intra-operative realignment of the vessels, if necessary. The inherent instability of a single intramedullary K-wire to rotational forces is avoided by inserting the second K-wire at the end of the procedure. Tendons The extensor tendons are always repaired, with an endto-end suture technique, immediately after bone shortening and fixation. Suturing of the extensor tendons provides additional stability to the replanted digit and in most cases is straightforward. Repair of the extensor

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tendons is always done primarily. Flexor tendon repair should be done primarily only in selected clean-cut amputations; otherwise reconstruction should be done as a secondary operation either as a one-stage or a twostage tendon graft procedure (Hunter, 1984; Soucacos, 1995b). Digital artery repair Arterial anastomosis takes place after bone shortening and fixation and extensor and flexor tendon repair. It is preferable to repair both digital arteries. Successful microvascular anastomosis requires a solid microsurgical technique, and anastomosis on normal intima under no tension. A pneumatic tourniquet around the upper arm should be used for each vascular anastomosis, as it will help decrease blood loss and improve operating time. The artery should be dissected until normal intima can be seen under high-power magnification. If normal intima cannot be approximated without tension, further bone shortening or, preferably, a vein graft are indicated. The arterial ends are also assessed for damage to the media or adventitia; if these are present, the artery needs to be resected further.

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is present (Zoubos, 1994). Following most microvascular procedures used in replantation, the rule of thumb is that when the part or area has developed pallor and loss of turgor (e.g. the area is pale with loss of capillary refill), then arterial insufficiency is present. On the other hand, when the area is cyanotic, congested and turgid, then venous insufficiency is present. If normal perfusion does not return, the patient must be returned to the operating room; if the patient is returned within the first 12–48 hours, some failures can be salvaged by re-doing a vein graft, removing thrombus or grafting to replace a previously unrecognized damaged segment of vessel. Congestion can be effectively relieved by the use of medicinal leeches. Although sub-acute complications due to infection are fairly frequent in digital replantations, they rarely result in loss of the replanted part. The most common chronic complications include cold intolerance, tendon adhesions and malunion. Cold intolerance is a common complaint in patients with digital replantation. It is related to the adequacy of digital perfusion, and provides an argument for maximizing the number of arteries repaired. Cold intolerance improves over time. Tendon adhesions are frequent, resulting in limited motion. In severe cases, tenolysis can be performed after three months.

Digital vein repair In order to repair two veins for each artery, veins may need to be mobilized or harvested. The most common errors are anastomosis under tension or wasting time trying to repair very small veins; only the largest veins should be anastomosed. The technique of venous anastomosis is in general similar to arterial anastomosis, but there are a few differences. Fewer sutures are required, as blood-flow is weaker than in arteries. In addition, since the venous wall is thinner and more fragile, the use of microclamps during the anastomosis procedure must be kept to a minimum to avoid injury by prolonged pressure which, in turn, may lead to necrosis of the venous wall. Digital nerves Repair of the digital nerves adheres to the same guidelines as repair of the flexor tendons within the tendon sheath. Thus, in cases with a clean-cut injury, direct end-to-end digital nerve coaptation is indicated. In all other situations, such as crush or avulsion type injuries, secondary procedures using a nerve graft or if the nerve gap is less than 2 cm, using a nerve conduit are recommended. Complications Inadequate perfusion is responsible for acute complications. The management of circulatory compromise depends upon whether arterial or venous insufficiency

Sensation and functional recovery Despite the difficulties encountered in replantation of their digits, the functional outcome appears to be better in children (Beris et al., 1995). The better recuperative ability of children compared with adults is demonstrated by their rapid nerve recovery and better sensibility. However, the assessment of static or moving 2-point discrimination is often difficult in the very young. The recovery of muscle function tends to be worse than the recovery of sensibility, particularly in hand injuries because of the relatively poor reinnervation of the intrinsic muscles of the hand after replantation. Overall, sensory re-education appears to improve the recovery of sensation and allow the patient to achieve his full potential for functional recovery. One of the major factors that determines success in replanting a digit appears to be the expertise of the surgeon. Factors such as age, amputation level, and type of the injury do not appear to affect to survival rate. Overall, replanted fingers in children have a lower survival rate than adults, but their functional results are uniformly superior.

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Received: 27 November 2000 Accepted after revision: 14 March 2001 Professor P N Soucacos, Department of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina 45 110, Greece. # 2001 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0595, available online at http://www.idealibrary.com on