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Major replantation surgery in the upper limb
Major Replantation Surgery in the Upper L i m b - - B . McC, O'Brien, A. M. Macleod, J. W. Hayhurst, W. A. Morrison, and H. Ishida
MAJOR REPLANTATION
SURGERY IN THE UPPER LIMB
B. McC. O ' B R I E N , A. M. M A C L E O D , J. W. H A Y H U R S T , W. A. M O R R I S O N , and H. I S H I D A , Melbourne The history of limb replantation surgery has been reviewed in several authors and the good long term functional results recorded (1972) will stimulate further endeavour in this field. The Sixth People's Shanghai (1973), recently reported 94 total replantations (84 successful) both upper (mainly) and lower limbs, 10% of these were children.
detail by by Malt Hospital, involving
The series at St. Vincent's Hospital, Melbourne is presented to highlight technical procedures which have proved to be successful and also to demonstrate difficulties encountered in pre-operative case assessment and late reconstructive surgery. Cases of severe vascular and other tissue damage without complete amputation are included as the problems encountered are as difficult as in the cases of complete amputation and the techniques of repair are identical. PRESENT SERIES There have been eight major limb replantations, seven involving the upper limb and one the lower limb. The ages of the patients ranged from two years to forty-four years. In the upper limb there were five complete amputations including four successes and two incomplete amputations which failed. The levels of injury varied from guillotine, moderate crush to avulsion with gross damage to muscle skin and vessels below the level of amputation including double fractures.
A number of other amputations were inspected but for various reasons such as head injuries, severe crush with massive bone and muscle loss and severe double amputation (Fig. 1) a decision was made against replantation. Sometimes the final decision could only be made in the operating room. CASE HISTORIES Case 1
A twenty-nine-year-old butcher fell against a band-saw and completely amputated his right (dominant) hand approximately 3 cm. above the wrist joint (Fig. 2). The hand was cooled immediately by ice, in a plastic bag, and the patient transported to hospital within thirty minutes of the accident. After the forearm bones were shortened by 2.5 cm. and fixed using oblique Kirschner wires, the tendons of extensor pollicis longus, extensor digitorum communis, and extensor carpi radialis longus were joined and four dorsal veins repaired. The dorsal skin was then sutured and the ulnar artery anastomosed thereby restoring circulation. Cooling was con-
Fig. la.
Amputation left arm of a four-year-old boy at the shoulder joint and almost total amputation with division of all main structures at the elbow level. Fig. lb. X-ray of the same arm. Fracture at lower end of humerus is present, A decis!on was made not to replant this arm.
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Maior Replantation Surgery in the Upper L i m b - - B . McC. O'Brien, A. M. Macleod, J. W. Hayhurst, W. A. Morrison, and H. lshida
Fig. 2a. Fig. 2b.
Guillotine amputation of right hand 3 cms. above the wrist. A t fifteen months, good flexion of wrist and of interphalangeal joints. Some restrictive adhesions of the extensor and flexor tendons at the wrist are present.
tinued until circulation was established. The median nerve, ulnar nerve and radial artery were then repaired as were the tendons of flexor pollicis longus, flexor digitorum profundus, and flexor carpi radialis; the superficial flexor tendons were shortened and the volar skin closed. The ischaemic time was seven hours and the operating time seven hours. Marked swelling on the second post-operative day necessitated decompression but convalescence was otherwise uneventful. Due to adherence of his long flexors at the site of replantation, the finger tips when in full flexion, reached to 4 cm. from the middle palmar crease. A f t e r one year tenolysis of the extensor and flexor tendons was necessary and this has given some improvement but full adherence has not been eliminated. Subsequently an opponens tendon transfer utilising a plantaris tendon graft extension of a superficial flexor tendon through the tdnar nerve canal has given improved opposition (Fig. 3). Fifteen months post-operatively there is sensation to light touch present at all finger tips, and his two point discrimination at this level is 1.5 cm. in both median and ulnar nerve distributions. He is using the hand although he has not yet returned to work. He has a 30 ° active flexion at the wrist joint with 15 ° of active extension and good stability. X-rays demonstrate good bone union and an arteriogram at six months shows patent- radial and ulnar arteries.
Fig. 3a. Fig. 3b. Fig. 3c. 218
A t fifteen months, almost full extension of the wrist and fingers. After opponens tendon transfer t h u m b can almost reach the little finger. Arteriogram at six months with patent radial and ulnar arteries, and united radius. The H a n d - - V o l . 6
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Major Replantation Surgery in the Upper L i m b - - B . McC. O'Brien, A. M. Macleod, J. W. Hayhurst, W. A. Morrison, and H. lshida
Fig. 4a.
Crush amputation left hand 4 cms. above the wrist in a twenty-five-year-old man. Perfusion had been attempted at a peripheral hospital. X-ray of the same hand. Arteriogram at six months showing a patent radial artery.
Fig. 4b. Fig. 4c. Case 2 A twenty-five-year-old right-handed labourer suffered a crush injury to his lower left forearm and an amputation proximal to the wrist joint resulted. The wound was untidy and was contaminated with dirt. The severed hand was cooled shortly after the accident and perfusion of the ulnar artery was attempted prior to referral to St. Vincent's Hospital (Fig. 4), Surgery was commenced six hours following the injury and after shortening both forearrr~ bones by 4 cm. fixation was obtained using intramedullary Knowles pins. The extensors of thumb and fingers and one radial wrist extensor were repaired and two dorsal veins anastomosed, the radial artery was then sutured and circulation re-established. Ischaemia time had been 9½ hours with cooling continuing throughout the surgery. A further three veins were then anastomosed and the dorsal skin closed. The flexor superficialis and flexor carpi ulnaris were resected and the flexor profundi, flexor pollicis longus and flexor carpi radialis were joined. The ulnar nerve was too badly contused to allow repair but the median nerve was repaired as were the ulnar artery and one of its venae comitantes. Decompression of the carpal tunnel and dorsal skin of the hand were performed prior to final skin closure which required a split skin graft on the ulnar aspect. Four months later inter-fascicular sural nerve grafts were inserted into the ulnar nerve defect.
Fig. 5a. Fig. 5b. Fig. 5c.
A t fifteen months. Almost complete extension of the fingers. After opponens tendon transfer, t h u m b can reach middle finger. Almost full flexion of the fingers.
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Major Replantation Surgery in the Upper L i m b - - B . McC. O'Brien, A. M. Macleod, J. W. Hayhurst, W. A. Morrison, and H. lshida One year following his injury the extensor pollicis brevis was rnobilised and joined, distal to the ulnar nerve canal, to the palmaris longus which had been attached to a superficial tendon to act as an opponens. The patient would not permit tendons from other donor areas to be touched. At fifteen months he has sensation present to all finger tips. There is useful wrist and finger movement with a two point discrimination of 1.5-2 cms. His finger tips on flexion come within 1.5 cm. from the middle palmar crease (Fig. 5). There is wasting of the small muscles but he can oppose the thumb tip to his middle finger. A n arteriogram at nine months demonstrated a patent radial artery, the ulnar artery having been damaged at the time of his nerve graft procedure. Case 3 A twenty-one-year-old right-handed man and a professional fisherman caught his left arm in a winch on a fishing boat, several hundred miles distant. The arm was avulsed in the midforearm and the median and ulnar nerve, some tendons and a long vein were hanging from the amputated arm (Fig. 6), and the advisability of replantation appeared in doubt. The stump was contaminated and the radius and ulna projected several inches. The skin was severely damaged and a friction burn was present in the cubital fossa. Compound dislocations of the proximal interphalangeal joints of the middle and ring fingers were present. Surgery commenced eight hours after the injury and cooling was continued until circulation was re-established, l0 cm. of the forearm bones were resected and fixation obtained with plates and screws. The extensor muscle bellies and dorsal skin were repaired prior to anastomosis of the ulnar artery and its venae comitantes, ischaemia time having been fifteen hours. The radial artery and a large volar vein were then repaired as were the median and ulnar nerves after resection of the damaged ends. The dislocated finger joints were reduced. Long anterior and posterior decompressions were performed and a friction burn in the cubital fossa excised and grafted with split thickness skin. Continuous intravenous heparinisation was commenced forty-eight hours post-operatively and discontinued after twelve days as his convalescence was uneventful. Return of movement to the wrist and fingers has only been slight after one year and two skin graft procedures have been necessary to correct a contracture at the elbow which now has a useful range of movement (Fig. 7). However, a good sensation has returned to the fingers with a two point discrimination of 2 cm. at the tips. A n arteriogram demonstrates a patent ulnar artery. Case 4 A sixteen-year-old boy riding a bicycle was struck by a car. He suffered a complete avulsion of his right arm immediately above the elbow (Fig. 8). There was approximately 10 cm. of nerve projecting from the upper arm with 4 cm. of exposed humerus. There was an additional fracture of the mid-shaft of the radius. The arm had been surrounded by ice in a plastfc bag since the accident. The humerus was shortened by 5 cm. and then plated. Radical debridement of the wound followed and the muscles joined as far as possible. Several large veins were repaired. The brachial artery divided at a higher level than usual and the radial and ulnar arteries were also repaired with one vena comitans. The arm was replanted and circulation restored after eleven and a half hours of ischaemia. The wound was then closed after good circulation had been established. The duration of operating time was nine and a half hours. The hand was pink with good capillary return. The forearm was noted to be oedematous but no fasciotomy was required. On the seventh post-operative day an excess ooze from the wound was noted, though circulation in the hand and fingers was still good, pus from the wound cultured pseudomonas aeruginosa and the patient was placed on Gentamycin. Further debridement of the wound was carried out and some maggots were removed. The ooze persisted and later an extensive fasciotomy was necessary with excision of dead muscle. Circulation of the hand remained good, but further survery on the tenth post-operative day demonstrated an extensive infection with much dead muscle. The arm was amputated following which his post-operative course was uneventful. Case 5 A seventeen-year-old boy received a partial amputation of his right upper arm. There was an almost complete severance of the right arm at the junction of the middle and lower thirds of the humerus and also a compound fracture of the radius and ulna. The radial and median nerves were intact and there was a small posterior skin-bridge with some muscle continuity. In the upper wound of the arm the basilic and cephalic veins were repaired after fixation of the humerus by plating. The radius and ulna were plated and a long saphenous vein graft inserted into the brachial artery defect. The ulnar nerve was repaired after the biceps and brachialis had been approximated and skin closure obtained using a free skin graft. Circulation returned after an ischaemic time of thirteen hours. 220
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Major Replantation Surgery in the Upper L i m b - - B . McC. O'Brien, A. M. Macleod, J. W. Hayhurst, W. A. Morrison, and H. lshida
Fig. 6.
Avulsion amputation of a twenty-one-year-old fisherman through the left forearm.
Fig. 7a. Fig. 7b. Fig. 7c.
After one year, extension at the elbow. Flexion of the elbow at one year. Arteriogram at six months with patent ulnar artery.
Fig. 8a. Fig. 8b.
Avulsion amputation lower end of humerus. Replantation unsuccessful. X-ray same patient with fractures also through the radius and ulna.
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Maior Replantation Surgery in the Upper L i m b - - B . McC. O'Brien, A. M. Macleod, J. W. Hayhurst, W. A. Morrison, and H. lshida In the immediate post-operative period circulation was adequate but it rapidly deteriorated and after further twenty-four hours without improvement amputation was performed because of the risks of gangrene, Case 6 A twenty-one-year-old man almost completely amputated his right arm just below the elbow when his car overturned. A long journey to hospital was required. There was a severe crushing injury just below the elbow but the median and radial nerves with a 3 cm. wide skin-bridge including some muscle remained intact. There was an extensive degloving injury of the skin of the forearm with gross contamination. The continuity of the median and radial nerves and the small soft-tissue warranted an attempt at replantation. After bony fixation using screws and plates, both the radial and ulnar arteries were repaired as were three dorsal veins. The ulnar nerve was transposed on to the volar aspect and the ends tacked together for later repair. Circulation was established after about 20 hours of ischaemia. 15 Units of blood were given during surgery. The fingers were warm with some capillary filling, but this slowed over a period of several days and on the fifth post-operative day the pulse could not be felt. The hand had a slightly bluish colour with a slower capillary return. The hand remained relatively unchanged, but on the eighth day it became cooler. A t re-operation, the arteries were found to be thrombosed and a circulation could not be re-established for any length of time despite the passage of Fogarty catheters, so the arm was amputated. His post-operative course was then uneventful. Case 7 A twenty-eight-year-old male amputated his left h a n d obliquely through the carpus after being caught in a carpet weaving machine (Fig. 9). The proximal row of carpal bones were excised and the wrist arthrodesed with two Kirsehner wires passed longitudinally through the second and fourth metacarpals into the radius and ulna. The extensor communi tendons with a long extensor to the t h u m b and three dorsal veins, were repaired and the skin sutured. The ulnar artery was joined using a reversed vein graft and the radial artery anastomosed on the dorsum as it passed between the two interosseous heads. Flexor pollicis longus, flexor profundus tendons and abductor pollicis longus were repaired as were the median and ulnar nerves. Split thickness skin grafts were required for part of the skin closure. Total ischaemia time was ten hours and operation time was seven hours. Post-operatively he made excellent recovery and no decompression was required. He was immobilised for two months. During this period his pins were removed due to a transient inflammation of the lower end of the ulna. His range of movement at four months is steadily improving (Fig. 10). The return of sensation has reached the level of the proximal interphalangeal joints. A n arteriogram at the same period demonstrates patent radial and ulnar arteries.
Fig. 9a. Fig. 9b. Fig. 9c. 222
A m p u t a t i o n of the left hand in a twenty-eight-year-old man, in a carpet loom (through the carpal joints). X-ray confirms the amputation through the carpal bones. The proximal carpal bones were removed. Arteriogram at four months with patent radial and ulnar arteries. The H a n d - - V o l . 6
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Major Replantation Surgery in the Upper Lirnb--B. McC. O'Brien, A. M. Macleod, J. W. Hayhurst, W. A. Morrison, and H. lshida
Fig. 10a. Good extension of the fingers at four months. Fig. 10b. Enco,araging flexion at four months. DISCUSSION
Patient selection has emerged as a most important factor. Some cases have been rejected for replantation because of other injuries, or extensive local damage. The oldest patient in this series has been forty, but others (Malt, 1972) have replanted in older age groups. It is necessary to consider the age of the patient, the dominance of the hand, his occupation and wishes and to consult with relatives as to his personality and any relevant history. The decision to replant is often a multifaceted one involving economic, social, psychological, and emotional factors. If possible the patient should be fully informed and participate in the decision. The final decision to replant or amputate is often not made until the time of surgery. What appears to be a badly mangled arm with considerable loss of tissue may on closer inspection be a disarrangement of parts with little actual tissue lost. Each system is examined during debridement until a clear understanding of the injury is obtained. Until a final decision is made the management of the case should proceed as if the replantation would take place. An accurate history of the type of injury is important and in a couple of cases this information has either been lacking or misleading. Guillotine and moderately crushed injuries as in digital replantations are suitable for replantation, but again the avulsion group presents great difficulties primarily and also in secondary reconstruction. Additional injuries at lower levels are the most important. Chen (1972) reports ten cases with double level injuries at the Sixth People's Hospital, Shanghai, with six survivals. Of three cases lost in our series one became grossly infected and was amputated despite satisfactory circulation in the hand and in the other two there was extensive muscle and skin damage from direct trauma. Avulsion injuries with extensive damage to skin, muscle or bone probably represent a contra-indication to replantation and this experience is confirmed by Cheng (1972) at the Chi Shui Tan Hospital, Peking. LIMB P R E S E R V A T I O N A N D P R E - O P E R A T I V E C A R E
Early cooling is essential. Satisfactory cooling may be obtained by placing the limb in a plastic bag and surrounding this bag with ice. Most of the beneficial effects of cooling probably are the result of the decreased overall metabolism of The H a n d - - V o l . 6
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Major Replantation Surgery in the Upper Lirnb--B. McC. O'Brien, A. M. Macleod, J. W. Hayhurst, W. A. Morrison, and H. lshida
the tissues with lower oxygen requirements and reduced accumulation of metabolic waste products. Experimentally cooling, prior to periods of ischaemia, has been shown to (1) reduce post-operative oedema (Eiken, 1964). (2) Increase postoperative blood flow. (3) Reduce post-operative shock and mortality (Eiken, 1964; Hamel and Moe, 1964). Chen's group (1972) has reported successful revascularisation up to thirty-six hours in major limb replantation. Though it would seem that larger replantations would not tolerate prolonged separation compared with digits due to the massive tissue involved, these experiences in China and our own where the maximum ischaemia time has been twenty hours, indicate that if cooling is instituted early, successful replantation can be achieved. Pre-operative Penicillin in large doses is given and radiological examination of both the proximal part and the amputated extremity are carried out to detect other bony injuries. A pump-oxygenator has been used experimentally in restoration of extremities (Lapchinsky, 1960; Snyder, 1960), however, we find no reports of its use clinically and do not believe it is indicated. If the period of ischaemia is approaching a critical time, priority is given to the re-establishment of arterial circulation. Immediately following the amputation the pressure in the vascular tree of the amputated part, acts to empty the part of blood. The unopposed vascular tone causes the vessels t o contract aiding in the outflow of blood and explaining the characteristic pallor of the amputated extremity and the paucity of blood in the perfusate of these extremities. The small amount of blood which remains at the small vessel level may be a beneficial buffer protecting the endothelium from the falling pH at this tissue level. There is no conclusive evidence to support perfusion of the amputated extremity. Clinical reports of replantation frequently emphasise that no clots were obtained at the time of perfusion and that the perfusate immediately became clear (Rosenkrantz, 1967; Bosa, 1967; Bains, 1970). Pre-operative perfusion involves manipulation and abnormal pressure of the vaseulature which may resutt in vascular damage. Prolonged perfusion may result in major decrease of potassium and magnesium, and manipulative attempts may damage vessel ends. Parenteral antibiotics are given as soon as possible and in this series Penicillin and Ampicillin have been used. Infection is frequently associated with replantation failure and B. coli pseudomonas are commonly cultured (Ramirez, 1967; Inoue, 1967). High dosage for gram positive organisms including Staphlycocci should also be provided and the appropriate Tetanus prophylaxis is also gwen. OPERATIVE TECHNIQUE
If the limb is completely amputated then two operating microscopes at low power are used to identify the various vessels and nerves. Thorough debridement is carried out removing all dead or doubtful tissue. BONE STABILISATION
Shortening allows opposition of important structures. Various methods have been used including Kirschner wires, intramedullary pins and plates. All appear to have their place depending on the situation of the bone and all can be successful. Chen (1972) steps the bone and uses one screw for fixation. He reports 5% non-union, correcting this by fliac cancellous bone grafts. Shortening of bone is performed in every case and usually in these fractures no less than 3 cms. 224
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Major Replantation Surgery in the Upper L i m b - - B . McC. O'Brien, A. M. Macleod, J. W. I-layhurst, W. A. Morrison, and H. lshida
Experimental work (Furnas, 1970) has illustrated that growth is not disturbed by replantation in the young and Chen's group (1972) confirms this clinically as 10% of their cases were children. In our four successful cases, in the upper limb, there was non-union of the radius in one case but with union of the ulna. Recently compression plates have been suggested to offer advantages in certain cases (Malt, 1972). MUSCLES A N D T E N D O N S
Due to the possibility of manipulation causing injury to fragile vascular anastomoses the deep muscles and tendons are repaired early. At lower levels one wrist extensor and a long extensor to each digit is joined, followed by the venous surgery. On the volar side one wrist flexor and five deep flexors (digital) are joined. If the period of ischaemia has been relatively short veins are anastomosed first followed by the arteries, but otherwise the arteries are connected first, allowing the veins to bleed until they too can be repaired. However, excessive blood loss must be expected in these circumstances. Usually twice as many veins as arteries are sutured and an attempt is made to suture veins in superficial and deep tissues. Frequently the venae comitantes are sufficiently large to be anastomosed. Asymmetry of diameter can be overcome to some extent by cutting the smaller vein obliquely or back to a Y junction. Delay and failure in microvascular surgery follows any attempt to utilise damaged arteries. Any vessel with intramural haemorrhage or unstable intima is resected until normal structure is seen through the microscope and a good flow obtained. Any artery which requires passage of a Fogarty catheter has further damage and should be resected more widely. The distal artery should be thoroughly examined within the limits of the wound and any lower wound explored to determine if important vessels or nerves had been damaged. Chen (1972) perfuses all limbs as a diagnostic measure and emphasises that in double level injuries, a reduced outflow on perfusion is an indication of vascular damage more distally. The success following vein grafting to arteries is well known and justifies radical resection. Review of the reported limb failures revealed arterial thrombosis to be the most common cause of failure (McNeill, 1970). Most of the failures were in replantations at or near the wrist where the diameter of the radial and ulnar arteries is usually about 3 mm. Patency rate of 3-4 mm vessels on experimental animals under ideal conditions with conventional techniques achieve only 75% patency (Jacobson, 1971). In a controlled study of the femoral arteries of dogs Henderson and colleagues (1973), compared results using 2 x magnification and 7-0 silk, and higher magnifications of the microscope and 10-0 nylon. In the first series there was only 75% patency whereas the microsurgical repairs yielded 100% patency. Using microsurgical techniques patency rates approaching 100% may be obtained for all healthy vessels 1 mm in diameter (Hayhurst and O'Brien, 1973). Studies of experimental replantation in dogs have shown almost total occlusion of the venous anastomoses between the third and fourteenth post-operative Venous repairs with conventional techniques are even less satisfactory. days and recanalisation beginning by the fifteenth day and complete by the thirtieth post-operative day (Reich, 1970). The H a n d - - V o l . 6
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Major Replantation Surgery in the Upper L i m b - - B . McC. O'Brien, A. M. Macleod, J. W. Hayhurst, W. A. Morrison, and H. lshida
Using microsurgical techniques and a single dose of Calcium heparin (Calciperine), O'Brien (1970) reported a 93% initial patency and 90% long term patency for veins 1.0-1.25 mm. in diameter. The superior patency rates achieved by microsurgical techniques make their use imperative in all cases. All the vascular anastomoses in this series utilised 10-0 atraumatic nylon and the Zeiss triploscope (O'Brien, 1970, 1973). NERVE REPAIRS
Primary repair of nerves is carried out whenever possible. With boneshortening it is usually feasible to resect all the damaged nerve inspected under the microscope and obtain a satisfactory repair with epineural sutures. In the successful cases the rate of nerve regeneration has parallelled that seen in simpler injuries. With a gross nerve deficiency the first stage of the nerve pedicle can be established sacrificing the ulnar nerve and suturing the distal ulnar nerve to the distal median or the proximal ulna to the proximal median and subsequently bringing down the vascularised pedicle of ulnar nerve to fill the gap in the median nerve. The aim in replantation surgery is to complete wherever possible primary union of important divided structures. SKIN
Deficiences in skin are corrected usually by skin-grafting and flaps have not been required at this stage. Shortening of the bone enables the skin to be approximated more easily. If however, the arterial union is established first then bleeding and swelling occurs earlier, and skin closure then may not be feasible. ANTICOAGULANT
THERAPY
A flexible approach is adopted with anticoagulants. If the operation proceeds smoothly and circulation is easily established then no anticoagulants are given during surgery. However, where there have been difficulties with the circulation then anticoagulants, e.g. Heparin, are instituted. In the three total hand replantations no anticoagulant therapy has been used, and only Aspirin, 1 gram daily, and Persantin, 250 mgm four times daily, postoperatively with a half litre 6% Macrodex, daily for three days. If Heparin is used then it is continued slowly, by intravenous infusion, until the tenth day maintaining the clotting time at 25-30 minutes and the Kaolin partial thromboplastin time beyond 55 seconds. Decompression has been found necessary in most cases unless there has been a gross injury which has resulted in a natural decompression. POST-OPERATIVE CARE
Elevation of the arm, immobilisation in a padded volar plaster, avoidance of circumferential dressings, close observation of capillary return, colour and warmth, are necessary. Dangers of arterial or venous thrombosis should be recognised. This will include in both cases a drop in temperature. In a venous obstruction which fortunately, has not been encountered in this series, there would be swelling and cyanosis, but with arterial obstruction lessening of capillary return and mottled blueness can occur, and in two cases this has been due to failure to resect a sufficiently wide segment of damaged vessel or to widespread vessel damage at a lower level injury. Pulsometers or plethysmographs should not be used over enthusiastically, as they are only ancillary to more important clinical observations. Movement of fingers should be instituted as soon as possible together with dynamic splinting and regular physiotherapy. 226
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Major Replantation Surgery in the Upper L i m b - - B . McC. O'Brien, A. M. Macleod, J. W. Hayhurst, W. A. Morrison, and H. Ishida
T h e p o o r results o b t a i n e d in cases of p a r t i a l a m p u t a t i o n m a y be due to distal d a m a g e following c o n t i n u a n c e of the i n j u r y a g e n t w h e r e a s in c o m p l e t e a m p u t a t i o n s the severed l i m b is r e m o v e d f r o m t h e t r a u m a . D a m a g e d m u s c l e w i t h s t a n d s a n o x i a p o o r l y a n d in these cases of distal d a m a g e it m a y be wise to re-establish c i r c u l a t i o n p r i m a r i l y even if it causes difficulties w i t h the r e p a i r of o t h e r structures. This applies to i n j u r i e s p r o x i m a l to the m i d - f o r e a r m w h e r e a large a m o u n t of m u s c l e is present. A s these are severe injuries a n d r e q u i r e l o n g p e r i o d s of r e h a b i l i t a t i o n , t h e e a r l y i n t r o d u c t i o n of a S o c i a l W o r k e r a n d a s h e l t e r e d w o r k s h o p a r e vital a n d i n d e e d this can be t h e m o s t difficult aspect of the t o t a l m a n a g e m e n t . It is essential t h a t the m o r a l e of t h e p a t i e n t be m a i n t a i n e d at a high level. SUMMARY
Seven cases of c o m p l e t e or i n c o m p l e t e a m p u t a t i o n s of the u p p e r e x t r e m i t y a r e p r e s e n t e d with a n overall survival r a t e of 67%. V a r i o u s aspects of o p e r a t i v e a n d p o s t - o p e r a t i v e m a n a g e m e n t a r e discussed. C a r e f u l selection of p a t i e n t s is e m p h a s i s e d a v o i d i n g r e p l a n t a t i o n of grossly d a m a g e d limbs. A n e e d f o r e a r l y r e h a b i l i t a t i o n is stressed. ACKNOWLEDGEMENTS
T h e assistance in s o m e of the cases of M r . S. Schofield, M r . W . Cole, M r . G. D. H. Miller, M r . B. J. D o o l e y , Mr. L. L e n e g h a n , a n d Mr. K. K i n g is gratefully acknowledged. REFERENCES
BALAS, P., GIANNIKAS, A. C., HARTO-GAROFILIDES, G., PLESSAS, S. (1970) The Present Status of Replantation of Amputated Extremities. Indications and Technical Considerations. Vascular Surgery 4: 190-209. BORA, F. W., DE SANTIS, D. (1967) Replantation of a Hand. A detailed report of procedures used in restoring a member which had been physiologically amputated by a metal-slicing machine, Pennsylvania Medicine 70: 53-56. CHEN, C. W. (1972) Personal Communication. CHENG, S. S. (1972) Personal Communication. EIKEN, O., NABRETH, D. C., MEYER, R. F., DETERLING, R. A. (1964) Limb Re-implantation. 1. The Technique and Immediate Results, 2. The Pathophysiologieal Effects, 3. Long-Term Evaluation. Archives of Surgery 88: 48-53, 54-65, 66-77. FURNAS, D, W. (1970) Growth And Development In Replanted Forelimbs. Plastic and Reconstructive Surgery 45: 445-453. HAMEL, A. L., and MOE, J. H. (1964) Effect of total ischaemia on hind limbs of dogs subjected to hypothermia. Surgery 55: 274-280. HAYHURST, J. W., and O'BRIEN, B. McC. (1973) An Experimental Study of Microvascular Technique, Patency Rates and Related Factors. (In preparation.) HENDERSON, P. N. Et al. (1973) An Assessment of Microvascular Techniques in the Anastomosis of 3-4 ram. Arteries. (Submitted for publication.) INOUE, T., TOYOSHIMA, Y., FUKUSUMI, H., UEMICHI, A., INUI, K., HARADA, S., HIROHASHI, K., KOTANI, T., and SHIRAHA, Y. (1967) Replantation of severed limbs. Journal of Cardiovascular Surgery 8:31 39. JACOBSON, J. H. (1971) Microsurgery. Current Problems in Surgery 3: 56. LAPCH1NSKY, A. G. (1960) Recent Results Of Experimental Transplantation Of Preserved Limbs And Kidneys And Possible Use Of This Technique In Clinical Practice. Annals of the New York Academy of Sciences 87: 539-571. MALT, R. A., REMENSNYDER, J. P., and HARRIS, W. H. (1972) Long Term Utility of Replanted Arms. Annals of Surgery 176: 334-342. McNEILL, I. F., and WILSON, J. S. (1970) The Problems of Limb Replacement. British Journal of Surgery 57: 365-377. O'BRIEN, B. McC., HENDERSON, P, N., BENNETT, R. C. and CROCK, G. W. (1970) Microvascular Surgical Technique. Medical Journal of Australia 1: 722-725. O'BRIEN, B. McC. (1970) The Triploscope: A Triple Operating Microscope. Plastic and Reconstructive Surgery 45: 279-281. The H a n d - - V o l . 6
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O'BRIEN, B. McC. (1973) A Modified Triploscope. British Journal of Plastic Surgery 26: 301-303. ROSENKRANTZ, J. G., SULLIVAN, R. C., WELCH, K., MILES, J. S., SADLER, K. M., PATON, B. C. (1967) Replantation of an Infant's Arm. New England Journal of Medicine 276: 60%612. RAMIREZ, M. Z., DUQUE, M., HERNANDEZ, L., LONDONO, A., and CADAVID, G. (1967) Reimplantation of Limbs. Plastic and Reconstructive Surgery 40: 315-324. REICH, M. P., HEMPHILL, J. E., and WHITE, J. W. (1970) Limb Replantation. An Experimental Model. Vascular Surgery 4: 7-18. Sixth People's Hospital, Shanghai, Severed Limb Replantation Research Institute (1973) Understanding and Progress of Replantation of Severed Limbs and Digits. Chinese Medical Journal 1: 3. SNYDER, C. C., KNOWLES, R. P., MAYER, P. W., and HOBBS, J. C. (1960) Extremity Replantation. Plastic and Reconstructive Surgery 26: 251-263.
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MAJOR REPLANTATION
SURGERY IN THE UPPER LIMB
B. McC. O ' B R I E N , A. M. M A C L E O D , J. W. H A Y H U R S T , W. A. M O R R I S O N , and H. I S H I D A , Melbourne The history of limb replantation surgery has been reviewed in several authors and the good long term functional results recorded (1972) will stimulate further endeavour in this field. The Sixth People's Shanghai (1973), recently reported 94 total replantations (84 successful) both upper (mainly) and lower limbs, 10% of these were children.
detail by by Malt Hospital, involving
The series at St. Vincent's Hospital, Melbourne is presented to highlight technical procedures which have proved to be successful and also to demonstrate difficulties encountered in pre-operative case assessment and late reconstructive surgery. Cases of severe vascular and other tissue damage without complete amputation are included as the problems encountered are as difficult as in the cases of complete amputation and the techniques of repair are identical. PRESENT SERIES There have been eight major limb replantations, seven involving the upper limb and one the lower limb. The ages of the patients ranged from two years to forty-four years. In the upper limb there were five complete amputations including four successes and two incomplete amputations which failed. The levels of injury varied from guillotine, moderate crush to avulsion with gross damage to muscle skin and vessels below the level of amputation including double fractures.
A number of other amputations were inspected but for various reasons such as head injuries, severe crush with massive bone and muscle loss and severe double amputation (Fig. 1) a decision was made against replantation. Sometimes the final decision could only be made in the operating room. CASE HISTORIES Case 1
A twenty-nine-year-old butcher fell against a band-saw and completely amputated his right (dominant) hand approximately 3 cm. above the wrist joint (Fig. 2). The hand was cooled immediately by ice, in a plastic bag, and the patient transported to hospital within thirty minutes of the accident. After the forearm bones were shortened by 2.5 cm. and fixed using oblique Kirschner wires, the tendons of extensor pollicis longus, extensor digitorum communis, and extensor carpi radialis longus were joined and four dorsal veins repaired. The dorsal skin was then sutured and the ulnar artery anastomosed thereby restoring circulation. Cooling was con-
Fig. la.
Amputation left arm of a four-year-old boy at the shoulder joint and almost total amputation with division of all main structures at the elbow level. Fig. lb. X-ray of the same arm. Fracture at lower end of humerus is present, A decis!on was made not to replant this arm.
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Fig. 2a. Fig. 2b.
Guillotine amputation of right hand 3 cms. above the wrist. A t fifteen months, good flexion of wrist and of interphalangeal joints. Some restrictive adhesions of the extensor and flexor tendons at the wrist are present.
tinued until circulation was established. The median nerve, ulnar nerve and radial artery were then repaired as were the tendons of flexor pollicis longus, flexor digitorum profundus, and flexor carpi radialis; the superficial flexor tendons were shortened and the volar skin closed. The ischaemic time was seven hours and the operating time seven hours. Marked swelling on the second post-operative day necessitated decompression but convalescence was otherwise uneventful. Due to adherence of his long flexors at the site of replantation, the finger tips when in full flexion, reached to 4 cm. from the middle palmar crease. A f t e r one year tenolysis of the extensor and flexor tendons was necessary and this has given some improvement but full adherence has not been eliminated. Subsequently an opponens tendon transfer utilising a plantaris tendon graft extension of a superficial flexor tendon through the tdnar nerve canal has given improved opposition (Fig. 3). Fifteen months post-operatively there is sensation to light touch present at all finger tips, and his two point discrimination at this level is 1.5 cm. in both median and ulnar nerve distributions. He is using the hand although he has not yet returned to work. He has a 30 ° active flexion at the wrist joint with 15 ° of active extension and good stability. X-rays demonstrate good bone union and an arteriogram at six months shows patent- radial and ulnar arteries.
Fig. 3a. Fig. 3b. Fig. 3c. 218
A t fifteen months, almost full extension of the wrist and fingers. After opponens tendon transfer t h u m b can almost reach the little finger. Arteriogram at six months with patent radial and ulnar arteries, and united radius. The H a n d - - V o l . 6
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Fig. 4a.
Crush amputation left hand 4 cms. above the wrist in a twenty-five-year-old man. Perfusion had been attempted at a peripheral hospital. X-ray of the same hand. Arteriogram at six months showing a patent radial artery.
Fig. 4b. Fig. 4c. Case 2 A twenty-five-year-old right-handed labourer suffered a crush injury to his lower left forearm and an amputation proximal to the wrist joint resulted. The wound was untidy and was contaminated with dirt. The severed hand was cooled shortly after the accident and perfusion of the ulnar artery was attempted prior to referral to St. Vincent's Hospital (Fig. 4), Surgery was commenced six hours following the injury and after shortening both forearrr~ bones by 4 cm. fixation was obtained using intramedullary Knowles pins. The extensors of thumb and fingers and one radial wrist extensor were repaired and two dorsal veins anastomosed, the radial artery was then sutured and circulation re-established. Ischaemia time had been 9½ hours with cooling continuing throughout the surgery. A further three veins were then anastomosed and the dorsal skin closed. The flexor superficialis and flexor carpi ulnaris were resected and the flexor profundi, flexor pollicis longus and flexor carpi radialis were joined. The ulnar nerve was too badly contused to allow repair but the median nerve was repaired as were the ulnar artery and one of its venae comitantes. Decompression of the carpal tunnel and dorsal skin of the hand were performed prior to final skin closure which required a split skin graft on the ulnar aspect. Four months later inter-fascicular sural nerve grafts were inserted into the ulnar nerve defect.
Fig. 5a. Fig. 5b. Fig. 5c.
A t fifteen months. Almost complete extension of the fingers. After opponens tendon transfer, t h u m b can reach middle finger. Almost full flexion of the fingers.
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Major Replantation Surgery in the Upper L i m b - - B . McC. O'Brien, A. M. Macleod, J. W. Hayhurst, W. A. Morrison, and H. lshida One year following his injury the extensor pollicis brevis was rnobilised and joined, distal to the ulnar nerve canal, to the palmaris longus which had been attached to a superficial tendon to act as an opponens. The patient would not permit tendons from other donor areas to be touched. At fifteen months he has sensation present to all finger tips. There is useful wrist and finger movement with a two point discrimination of 1.5-2 cms. His finger tips on flexion come within 1.5 cm. from the middle palmar crease (Fig. 5). There is wasting of the small muscles but he can oppose the thumb tip to his middle finger. A n arteriogram at nine months demonstrated a patent radial artery, the ulnar artery having been damaged at the time of his nerve graft procedure. Case 3 A twenty-one-year-old right-handed man and a professional fisherman caught his left arm in a winch on a fishing boat, several hundred miles distant. The arm was avulsed in the midforearm and the median and ulnar nerve, some tendons and a long vein were hanging from the amputated arm (Fig. 6), and the advisability of replantation appeared in doubt. The stump was contaminated and the radius and ulna projected several inches. The skin was severely damaged and a friction burn was present in the cubital fossa. Compound dislocations of the proximal interphalangeal joints of the middle and ring fingers were present. Surgery commenced eight hours after the injury and cooling was continued until circulation was re-established, l0 cm. of the forearm bones were resected and fixation obtained with plates and screws. The extensor muscle bellies and dorsal skin were repaired prior to anastomosis of the ulnar artery and its venae comitantes, ischaemia time having been fifteen hours. The radial artery and a large volar vein were then repaired as were the median and ulnar nerves after resection of the damaged ends. The dislocated finger joints were reduced. Long anterior and posterior decompressions were performed and a friction burn in the cubital fossa excised and grafted with split thickness skin. Continuous intravenous heparinisation was commenced forty-eight hours post-operatively and discontinued after twelve days as his convalescence was uneventful. Return of movement to the wrist and fingers has only been slight after one year and two skin graft procedures have been necessary to correct a contracture at the elbow which now has a useful range of movement (Fig. 7). However, a good sensation has returned to the fingers with a two point discrimination of 2 cm. at the tips. A n arteriogram demonstrates a patent ulnar artery. Case 4 A sixteen-year-old boy riding a bicycle was struck by a car. He suffered a complete avulsion of his right arm immediately above the elbow (Fig. 8). There was approximately 10 cm. of nerve projecting from the upper arm with 4 cm. of exposed humerus. There was an additional fracture of the mid-shaft of the radius. The arm had been surrounded by ice in a plastfc bag since the accident. The humerus was shortened by 5 cm. and then plated. Radical debridement of the wound followed and the muscles joined as far as possible. Several large veins were repaired. The brachial artery divided at a higher level than usual and the radial and ulnar arteries were also repaired with one vena comitans. The arm was replanted and circulation restored after eleven and a half hours of ischaemia. The wound was then closed after good circulation had been established. The duration of operating time was nine and a half hours. The hand was pink with good capillary return. The forearm was noted to be oedematous but no fasciotomy was required. On the seventh post-operative day an excess ooze from the wound was noted, though circulation in the hand and fingers was still good, pus from the wound cultured pseudomonas aeruginosa and the patient was placed on Gentamycin. Further debridement of the wound was carried out and some maggots were removed. The ooze persisted and later an extensive fasciotomy was necessary with excision of dead muscle. Circulation of the hand remained good, but further survery on the tenth post-operative day demonstrated an extensive infection with much dead muscle. The arm was amputated following which his post-operative course was uneventful. Case 5 A seventeen-year-old boy received a partial amputation of his right upper arm. There was an almost complete severance of the right arm at the junction of the middle and lower thirds of the humerus and also a compound fracture of the radius and ulna. The radial and median nerves were intact and there was a small posterior skin-bridge with some muscle continuity. In the upper wound of the arm the basilic and cephalic veins were repaired after fixation of the humerus by plating. The radius and ulna were plated and a long saphenous vein graft inserted into the brachial artery defect. The ulnar nerve was repaired after the biceps and brachialis had been approximated and skin closure obtained using a free skin graft. Circulation returned after an ischaemic time of thirteen hours. 220
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Fig. 6.
Avulsion amputation of a twenty-one-year-old fisherman through the left forearm.
Fig. 7a. Fig. 7b. Fig. 7c.
After one year, extension at the elbow. Flexion of the elbow at one year. Arteriogram at six months with patent ulnar artery.
Fig. 8a. Fig. 8b.
Avulsion amputation lower end of humerus. Replantation unsuccessful. X-ray same patient with fractures also through the radius and ulna.
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Maior Replantation Surgery in the Upper L i m b - - B . McC. O'Brien, A. M. Macleod, J. W. Hayhurst, W. A. Morrison, and H. lshida In the immediate post-operative period circulation was adequate but it rapidly deteriorated and after further twenty-four hours without improvement amputation was performed because of the risks of gangrene, Case 6 A twenty-one-year-old man almost completely amputated his right arm just below the elbow when his car overturned. A long journey to hospital was required. There was a severe crushing injury just below the elbow but the median and radial nerves with a 3 cm. wide skin-bridge including some muscle remained intact. There was an extensive degloving injury of the skin of the forearm with gross contamination. The continuity of the median and radial nerves and the small soft-tissue warranted an attempt at replantation. After bony fixation using screws and plates, both the radial and ulnar arteries were repaired as were three dorsal veins. The ulnar nerve was transposed on to the volar aspect and the ends tacked together for later repair. Circulation was established after about 20 hours of ischaemia. 15 Units of blood were given during surgery. The fingers were warm with some capillary filling, but this slowed over a period of several days and on the fifth post-operative day the pulse could not be felt. The hand had a slightly bluish colour with a slower capillary return. The hand remained relatively unchanged, but on the eighth day it became cooler. A t re-operation, the arteries were found to be thrombosed and a circulation could not be re-established for any length of time despite the passage of Fogarty catheters, so the arm was amputated. His post-operative course was then uneventful. Case 7 A twenty-eight-year-old male amputated his left h a n d obliquely through the carpus after being caught in a carpet weaving machine (Fig. 9). The proximal row of carpal bones were excised and the wrist arthrodesed with two Kirsehner wires passed longitudinally through the second and fourth metacarpals into the radius and ulna. The extensor communi tendons with a long extensor to the t h u m b and three dorsal veins, were repaired and the skin sutured. The ulnar artery was joined using a reversed vein graft and the radial artery anastomosed on the dorsum as it passed between the two interosseous heads. Flexor pollicis longus, flexor profundus tendons and abductor pollicis longus were repaired as were the median and ulnar nerves. Split thickness skin grafts were required for part of the skin closure. Total ischaemia time was ten hours and operation time was seven hours. Post-operatively he made excellent recovery and no decompression was required. He was immobilised for two months. During this period his pins were removed due to a transient inflammation of the lower end of the ulna. His range of movement at four months is steadily improving (Fig. 10). The return of sensation has reached the level of the proximal interphalangeal joints. A n arteriogram at the same period demonstrates patent radial and ulnar arteries.
Fig. 9a. Fig. 9b. Fig. 9c. 222
A m p u t a t i o n of the left hand in a twenty-eight-year-old man, in a carpet loom (through the carpal joints). X-ray confirms the amputation through the carpal bones. The proximal carpal bones were removed. Arteriogram at four months with patent radial and ulnar arteries. The H a n d - - V o l . 6
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Fig. 10a. Good extension of the fingers at four months. Fig. 10b. Enco,araging flexion at four months. DISCUSSION
Patient selection has emerged as a most important factor. Some cases have been rejected for replantation because of other injuries, or extensive local damage. The oldest patient in this series has been forty, but others (Malt, 1972) have replanted in older age groups. It is necessary to consider the age of the patient, the dominance of the hand, his occupation and wishes and to consult with relatives as to his personality and any relevant history. The decision to replant is often a multifaceted one involving economic, social, psychological, and emotional factors. If possible the patient should be fully informed and participate in the decision. The final decision to replant or amputate is often not made until the time of surgery. What appears to be a badly mangled arm with considerable loss of tissue may on closer inspection be a disarrangement of parts with little actual tissue lost. Each system is examined during debridement until a clear understanding of the injury is obtained. Until a final decision is made the management of the case should proceed as if the replantation would take place. An accurate history of the type of injury is important and in a couple of cases this information has either been lacking or misleading. Guillotine and moderately crushed injuries as in digital replantations are suitable for replantation, but again the avulsion group presents great difficulties primarily and also in secondary reconstruction. Additional injuries at lower levels are the most important. Chen (1972) reports ten cases with double level injuries at the Sixth People's Hospital, Shanghai, with six survivals. Of three cases lost in our series one became grossly infected and was amputated despite satisfactory circulation in the hand and in the other two there was extensive muscle and skin damage from direct trauma. Avulsion injuries with extensive damage to skin, muscle or bone probably represent a contra-indication to replantation and this experience is confirmed by Cheng (1972) at the Chi Shui Tan Hospital, Peking. LIMB P R E S E R V A T I O N A N D P R E - O P E R A T I V E C A R E
Early cooling is essential. Satisfactory cooling may be obtained by placing the limb in a plastic bag and surrounding this bag with ice. Most of the beneficial effects of cooling probably are the result of the decreased overall metabolism of The H a n d - - V o l . 6
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the tissues with lower oxygen requirements and reduced accumulation of metabolic waste products. Experimentally cooling, prior to periods of ischaemia, has been shown to (1) reduce post-operative oedema (Eiken, 1964). (2) Increase postoperative blood flow. (3) Reduce post-operative shock and mortality (Eiken, 1964; Hamel and Moe, 1964). Chen's group (1972) has reported successful revascularisation up to thirty-six hours in major limb replantation. Though it would seem that larger replantations would not tolerate prolonged separation compared with digits due to the massive tissue involved, these experiences in China and our own where the maximum ischaemia time has been twenty hours, indicate that if cooling is instituted early, successful replantation can be achieved. Pre-operative Penicillin in large doses is given and radiological examination of both the proximal part and the amputated extremity are carried out to detect other bony injuries. A pump-oxygenator has been used experimentally in restoration of extremities (Lapchinsky, 1960; Snyder, 1960), however, we find no reports of its use clinically and do not believe it is indicated. If the period of ischaemia is approaching a critical time, priority is given to the re-establishment of arterial circulation. Immediately following the amputation the pressure in the vascular tree of the amputated part, acts to empty the part of blood. The unopposed vascular tone causes the vessels t o contract aiding in the outflow of blood and explaining the characteristic pallor of the amputated extremity and the paucity of blood in the perfusate of these extremities. The small amount of blood which remains at the small vessel level may be a beneficial buffer protecting the endothelium from the falling pH at this tissue level. There is no conclusive evidence to support perfusion of the amputated extremity. Clinical reports of replantation frequently emphasise that no clots were obtained at the time of perfusion and that the perfusate immediately became clear (Rosenkrantz, 1967; Bosa, 1967; Bains, 1970). Pre-operative perfusion involves manipulation and abnormal pressure of the vaseulature which may resutt in vascular damage. Prolonged perfusion may result in major decrease of potassium and magnesium, and manipulative attempts may damage vessel ends. Parenteral antibiotics are given as soon as possible and in this series Penicillin and Ampicillin have been used. Infection is frequently associated with replantation failure and B. coli pseudomonas are commonly cultured (Ramirez, 1967; Inoue, 1967). High dosage for gram positive organisms including Staphlycocci should also be provided and the appropriate Tetanus prophylaxis is also gwen. OPERATIVE TECHNIQUE
If the limb is completely amputated then two operating microscopes at low power are used to identify the various vessels and nerves. Thorough debridement is carried out removing all dead or doubtful tissue. BONE STABILISATION
Shortening allows opposition of important structures. Various methods have been used including Kirschner wires, intramedullary pins and plates. All appear to have their place depending on the situation of the bone and all can be successful. Chen (1972) steps the bone and uses one screw for fixation. He reports 5% non-union, correcting this by fliac cancellous bone grafts. Shortening of bone is performed in every case and usually in these fractures no less than 3 cms. 224
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Experimental work (Furnas, 1970) has illustrated that growth is not disturbed by replantation in the young and Chen's group (1972) confirms this clinically as 10% of their cases were children. In our four successful cases, in the upper limb, there was non-union of the radius in one case but with union of the ulna. Recently compression plates have been suggested to offer advantages in certain cases (Malt, 1972). MUSCLES A N D T E N D O N S
Due to the possibility of manipulation causing injury to fragile vascular anastomoses the deep muscles and tendons are repaired early. At lower levels one wrist extensor and a long extensor to each digit is joined, followed by the venous surgery. On the volar side one wrist flexor and five deep flexors (digital) are joined. If the period of ischaemia has been relatively short veins are anastomosed first followed by the arteries, but otherwise the arteries are connected first, allowing the veins to bleed until they too can be repaired. However, excessive blood loss must be expected in these circumstances. Usually twice as many veins as arteries are sutured and an attempt is made to suture veins in superficial and deep tissues. Frequently the venae comitantes are sufficiently large to be anastomosed. Asymmetry of diameter can be overcome to some extent by cutting the smaller vein obliquely or back to a Y junction. Delay and failure in microvascular surgery follows any attempt to utilise damaged arteries. Any vessel with intramural haemorrhage or unstable intima is resected until normal structure is seen through the microscope and a good flow obtained. Any artery which requires passage of a Fogarty catheter has further damage and should be resected more widely. The distal artery should be thoroughly examined within the limits of the wound and any lower wound explored to determine if important vessels or nerves had been damaged. Chen (1972) perfuses all limbs as a diagnostic measure and emphasises that in double level injuries, a reduced outflow on perfusion is an indication of vascular damage more distally. The success following vein grafting to arteries is well known and justifies radical resection. Review of the reported limb failures revealed arterial thrombosis to be the most common cause of failure (McNeill, 1970). Most of the failures were in replantations at or near the wrist where the diameter of the radial and ulnar arteries is usually about 3 mm. Patency rate of 3-4 mm vessels on experimental animals under ideal conditions with conventional techniques achieve only 75% patency (Jacobson, 1971). In a controlled study of the femoral arteries of dogs Henderson and colleagues (1973), compared results using 2 x magnification and 7-0 silk, and higher magnifications of the microscope and 10-0 nylon. In the first series there was only 75% patency whereas the microsurgical repairs yielded 100% patency. Using microsurgical techniques patency rates approaching 100% may be obtained for all healthy vessels 1 mm in diameter (Hayhurst and O'Brien, 1973). Studies of experimental replantation in dogs have shown almost total occlusion of the venous anastomoses between the third and fourteenth post-operative Venous repairs with conventional techniques are even less satisfactory. days and recanalisation beginning by the fifteenth day and complete by the thirtieth post-operative day (Reich, 1970). The H a n d - - V o l . 6
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Using microsurgical techniques and a single dose of Calcium heparin (Calciperine), O'Brien (1970) reported a 93% initial patency and 90% long term patency for veins 1.0-1.25 mm. in diameter. The superior patency rates achieved by microsurgical techniques make their use imperative in all cases. All the vascular anastomoses in this series utilised 10-0 atraumatic nylon and the Zeiss triploscope (O'Brien, 1970, 1973). NERVE REPAIRS
Primary repair of nerves is carried out whenever possible. With boneshortening it is usually feasible to resect all the damaged nerve inspected under the microscope and obtain a satisfactory repair with epineural sutures. In the successful cases the rate of nerve regeneration has parallelled that seen in simpler injuries. With a gross nerve deficiency the first stage of the nerve pedicle can be established sacrificing the ulnar nerve and suturing the distal ulnar nerve to the distal median or the proximal ulna to the proximal median and subsequently bringing down the vascularised pedicle of ulnar nerve to fill the gap in the median nerve. The aim in replantation surgery is to complete wherever possible primary union of important divided structures. SKIN
Deficiences in skin are corrected usually by skin-grafting and flaps have not been required at this stage. Shortening of the bone enables the skin to be approximated more easily. If however, the arterial union is established first then bleeding and swelling occurs earlier, and skin closure then may not be feasible. ANTICOAGULANT
THERAPY
A flexible approach is adopted with anticoagulants. If the operation proceeds smoothly and circulation is easily established then no anticoagulants are given during surgery. However, where there have been difficulties with the circulation then anticoagulants, e.g. Heparin, are instituted. In the three total hand replantations no anticoagulant therapy has been used, and only Aspirin, 1 gram daily, and Persantin, 250 mgm four times daily, postoperatively with a half litre 6% Macrodex, daily for three days. If Heparin is used then it is continued slowly, by intravenous infusion, until the tenth day maintaining the clotting time at 25-30 minutes and the Kaolin partial thromboplastin time beyond 55 seconds. Decompression has been found necessary in most cases unless there has been a gross injury which has resulted in a natural decompression. POST-OPERATIVE CARE
Elevation of the arm, immobilisation in a padded volar plaster, avoidance of circumferential dressings, close observation of capillary return, colour and warmth, are necessary. Dangers of arterial or venous thrombosis should be recognised. This will include in both cases a drop in temperature. In a venous obstruction which fortunately, has not been encountered in this series, there would be swelling and cyanosis, but with arterial obstruction lessening of capillary return and mottled blueness can occur, and in two cases this has been due to failure to resect a sufficiently wide segment of damaged vessel or to widespread vessel damage at a lower level injury. Pulsometers or plethysmographs should not be used over enthusiastically, as they are only ancillary to more important clinical observations. Movement of fingers should be instituted as soon as possible together with dynamic splinting and regular physiotherapy. 226
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T h e p o o r results o b t a i n e d in cases of p a r t i a l a m p u t a t i o n m a y be due to distal d a m a g e following c o n t i n u a n c e of the i n j u r y a g e n t w h e r e a s in c o m p l e t e a m p u t a t i o n s the severed l i m b is r e m o v e d f r o m t h e t r a u m a . D a m a g e d m u s c l e w i t h s t a n d s a n o x i a p o o r l y a n d in these cases of distal d a m a g e it m a y be wise to re-establish c i r c u l a t i o n p r i m a r i l y even if it causes difficulties w i t h the r e p a i r of o t h e r structures. This applies to i n j u r i e s p r o x i m a l to the m i d - f o r e a r m w h e r e a large a m o u n t of m u s c l e is present. A s these are severe injuries a n d r e q u i r e l o n g p e r i o d s of r e h a b i l i t a t i o n , t h e e a r l y i n t r o d u c t i o n of a S o c i a l W o r k e r a n d a s h e l t e r e d w o r k s h o p a r e vital a n d i n d e e d this can be t h e m o s t difficult aspect of the t o t a l m a n a g e m e n t . It is essential t h a t the m o r a l e of t h e p a t i e n t be m a i n t a i n e d at a high level. SUMMARY
Seven cases of c o m p l e t e or i n c o m p l e t e a m p u t a t i o n s of the u p p e r e x t r e m i t y a r e p r e s e n t e d with a n overall survival r a t e of 67%. V a r i o u s aspects of o p e r a t i v e a n d p o s t - o p e r a t i v e m a n a g e m e n t a r e discussed. C a r e f u l selection of p a t i e n t s is e m p h a s i s e d a v o i d i n g r e p l a n t a t i o n of grossly d a m a g e d limbs. A n e e d f o r e a r l y r e h a b i l i t a t i o n is stressed. ACKNOWLEDGEMENTS
T h e assistance in s o m e of the cases of M r . S. Schofield, M r . W . Cole, M r . G. D. H. Miller, M r . B. J. D o o l e y , Mr. L. L e n e g h a n , a n d Mr. K. K i n g is gratefully acknowledged. REFERENCES
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O'BRIEN, B. McC. (1973) A Modified Triploscope. British Journal of Plastic Surgery 26: 301-303. ROSENKRANTZ, J. G., SULLIVAN, R. C., WELCH, K., MILES, J. S., SADLER, K. M., PATON, B. C. (1967) Replantation of an Infant's Arm. New England Journal of Medicine 276: 60%612. RAMIREZ, M. Z., DUQUE, M., HERNANDEZ, L., LONDONO, A., and CADAVID, G. (1967) Reimplantation of Limbs. Plastic and Reconstructive Surgery 40: 315-324. REICH, M. P., HEMPHILL, J. E., and WHITE, J. W. (1970) Limb Replantation. An Experimental Model. Vascular Surgery 4: 7-18. Sixth People's Hospital, Shanghai, Severed Limb Replantation Research Institute (1973) Understanding and Progress of Replantation of Severed Limbs and Digits. Chinese Medical Journal 1: 3. SNYDER, C. C., KNOWLES, R. P., MAYER, P. W., and HOBBS, J. C. (1960) Extremity Replantation. Plastic and Reconstructive Surgery 26: 251-263.
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