Replantation in the mutilated hand

Hand Clin 19 (2003) 89–120

Replantation in the mutilated hand Bradon J. Wilhelmi, MDa,*, W.P. Andrew Lee, MDb, Geert I. Pagensteert, MDc, James W. May Jr, MDd a

Hand /Microsurgery, The Plastic Surgery Institute at Southern Illinois University School of Medicine, 747 North Rutledge, 3rd Floor, Springfield, Illinois 62794, USA b Division of Plastic Surgery, Hand Surgery, University of Pittsburgh School of Medicine, PA, USA c Surgery Resident, Freiberg, Germany d Division of Plastic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA

The treatment of the mutilated hand is perhaps the most challenging acute hand injury that hand surgeons treat. Many of these injuries involve the repair of devascularized and amputated parts of the upper extremity. The decision to attempt replantation and the techniques involved in replantation of amputated parts are often extremely difficult. Thousands of severed body parts have been reattached since the first replant 40 years ago, preserving a quality of life not provided by the void remaining after amputation. Ronald Malt performed the first replantation on May 23, 1962 at the Massachusetts General Hospital for a 12year-old boy who amputated his right arm in a train accident [1]. The level of amputation occurred at the neck of the humerus (Fig. 1). The osteosynthesis for this replantation was done with a steel rod through the humerus. The brachial artery, both communicating brachial veins, and the median, ulnar, and radial nerves were repaired with this replantation (Fig. 2). He performed another replant and in 1964 published a report on both replantations in the Journal of the American Medical Association (JAMA) [1] (Fig. 3). Later, Malt reported that the patient had some recovery of function of the replanted right arm after wrist arthrodesis and tendon transfers [2] (Fig. 4). Technologic advances and the use of the microscope have made possible the replantation

* Corresponding author. E-mail address: [email protected] (B.J. Wilhelmi).

of other parts including the thumb, fingers, ear, scalp, facial parts, and genitalia (6,12,13,16,20,29, 31,34,44,45,47,55,67–80).

Indications Not all amputees benefit from or are candidates for replantation. The decision to attempt replantation of a severed part is influenced by many factors, including the importance of the part, level of injury, expected return of function, and mechanism of injury. Thumb and multiple finger replants should be attempted, as function is severely compromised without opposition [3– 6]. Moreover, functional outcomes following replantation vary significantly with the level of injury. Good functional results can be achieved with replantation of injuries at the level of the fingers distal to the flexor superficialis insertion, the hand at the wrist, and the upper extremity at the distal forearm [7–11] (Fig. 5). Replantation of the above elbow amputation should be attempted for elbow preservation, even though the chance for nerve recovery is low. If subsequent nerve regeneration is inadequate after upper arm replantation, revision amputation at the mid forearm level can then allow for a below elbow prosthesis [7]. A below elbow prosthesis with a gravity activated grip is more functional than an above elbow prostheses. Less functional recovery is expected for replants at certain levels including amputations proximal to flexor superficialis insertion within zone II of the fingers and at the muscle belly and elbow level.

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Fig. 1. Ronald Malt with his patient, the first to undergo a replant procedure. Used with permission from Williams Wilkins.

As zone II replants can be expected to result in stiffness and rehabilitation that significantly delays return to work with minimal or no functional benefit, a relative contraindication to replantation exists for single digits amputated within the zone II level [12]. Replantation of zone II finger amputations have been justified in Japan, so patients can avoid being confused with Japanese gangsters (or Yakuza) who amputate their finger as a symbol of devotion to their mob boss. Perhaps the most predictive indicator for success with replantation is the mechanism of injury. O’Brien has demonstrated significantly higher success rates with replantations of guillotine versus avulsion amputations [5]. It may be an unrealistic expectation to successfully replant severely crushed and mangled body parts. Avulsion injuries with traction along the neurovascular bundles create intimal tears and disruption of small branches to the skin. Small hematomas seen in the skin along the course of the neurovascular bundle result in the ‘‘red line sign.’’ This sign sig-

Fig. 2. The first replant was performed at the level of the humerus and involved repair of ulnar, median, and radial nerves and the brachial artery and venae commitante. Used with permission from Williams Wilkins.

nifies such detrimental injury to the neurovascular bundle that replantation is often fraught with poor success. Replantation attempts in digits with the red line sign require vein grafting across this zone of injury. Another indication of injury to the vessels of an amputated digit is the ‘‘ribbon sign.’’ The ribbon sign is an indication of torsion and stretch on a vessel. The vessel resembles a ribbon that has been stretched and curled for decoration on a birthday present. Vessels that have the ribbon sign often are not amenable to sustaining blood flow, precluding replantation attempts [13] (Fig. 6). Two other relative contraindications to replantation include multiple level injuries and mentally unstable patients. The only absolute contraindication to replantation exists when associated injuries or preexisting illness preclude a prolonged and complex operation. In this circumstance temporary ectopic replantation has been described for preservation of the amputated

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Fig. 3. Title page of the report for the first replantation ever performed. (From Malt RA, McKhann CF. Replantation of severed arms. JAMA 1964;189(10):716–22; with permission.)

extremity before eventual elective replantation later [14–16] (Fig. 7). Preoperative considerations Replantation of arms, hands, digits, or even fingertips has become common in various institutions. Remote physicians, paramedics, and even the patients themselves are more educated on the possibility of replantation. Because of this, it is common to have the amputated part arrive with the patient at the emergency department. Even if not replantable, this amputated part can provide a valuable tissue source for reconstruction. The amputated part should be wrapped in a saline moistened gauze sponge and placed in a plastic bag. The plastic bag should be sealed and placed on ice (Fig. 8). The amputated part should not be placed directly on ice because this can result in a frostbite injury to the tissue [17]. The part should not be immersed in water because this has been demonstrated by Urbaniak to make digital vessel repair more difficult and less reliable

[18,19]. Bleeding vessels in the stump should not be clamped. Hemostatic control of the stump can be achieved with a compressive dressing and elevation. The recommended ischemia times for reliable success with replantation are 12 hours of warm and 24 hours of cold ischemia for digits, and 6 hours of warm and 12 hours of cold ischemia for major replants (ie, parts containing muscle). Reports of successful replantation after longer ischemia times exist [20–24] (Table 1). May reported a successful digit replantation after 39 hours of cold ischemia, the seventh of a sevenfinger replant case [21] (Fig. 9). Subsequently, Wei reported successful digital replantations after 84, 86, and 94 hours of cold ischemia [24]. The minimization of ischemia time is more critical in replantation of limbs proximal to the digits. In such cases, a temporary shunt to the amputated limb may be beneficial [14–16]. Before surgery, radiographs of the amputated parts and the stump should be performed to determine the levels of injury and suitability for

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Fig. 4. The first replantation several years after tendon transfers and wrist arthrodesis. Used with permission from Williams Wilkins.

replantation. Both parts should be photographed for documentation. An informed consent should be obtained, discussing the pros and cons with the patient and family regarding the failure rates, length of rehabilitation, realistic expectation of sensation, mobility, and function. The preoperative preparation also should include prophylactic antibiotics, updating the patient’s tetanus status, fluid resuscitation to prevent hypotension, warming the patient to prevent hypothermia and vasoconstriction/spasm, Foley insertion for volume monitoring, and protection of pressure points during an expected long operation.

Operative considerations The preparation of the amputated part can be initiated before the patient is brought to the operating room. This preparation is performed on a back table under sterile conditions in the operating room. The use of a microscope assists with the assessment of the digital vessels

Fig. 5. Levels of replantation. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

for replantation. Signs of arterial damage should be noted, including the telescope, cobweb, and ribbon signs or terminal thrombosis, which would require freshening of the vessel [25] (Fig. 10). Resection of the vessel distal to the zone of injury may result in a defect requiring a vein graft that should be harvested before osteosynthesis to minimize warm ischemia time. If the amputated part is grossly contaminated, it should be cleansed gently with Normal Saline (N/S) irrigation. Care must be taken not to further injure the digital vessels or soft tissue. The neurovascular structures of the fingers are exposed with either bilateral longitudinal incisions in the midaxial line or with volar zigzag and dorsal longitudinal incisions [25,26] (Fig. 11). The neurovascular structures are then identified and tagged with 5-0 nylon sutures or hemaclips to facilitate and expedite identification at the time of coaptation.

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Fig. 6. (A) The red line and ribbon signs are poor prognostic signs for replantation. (From Boulas HJ. Amputations of the fingers and hand: indications for replantation. Journal of the American Academy of Orthopaedic Surgeons 1998;6(2):101; with permission.) (B) This patient degloved a hand in a log crusher-splitter, resulting in multilevel neurovascular and bone injuries.

Fig. 7. (A,B) This patient underwent ectopic implantation of an amputated hand before eventual replantation when he was stable from other injuries. (From Chernofsky MA, Sauer PF. Temporary ectopic implantation. The Journal of the Hand Surgery 1990;15A(6):913; with permission).

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Fig. 8. The amputated part is wrapped in gauze and placed in a plastic bag. The plastic bag is set on ice. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

Many surgeons prefer to shorten the bone to avoid the potential need for arterial, venous, and nerve grafts later. The tagged neurovascular structures are gently relocated during the bone shortening (Fig. 12A). Approximately 5–10 mm of bone shortening may be necessary for tension-free vessel repairs. Through the bony shortening, nerve or vein grafts may be avoided [27]. The bone shortening should be performed on the amputated part if possible, to retain length should the replant fail.

Table 1 Longest reported replantation

ischemia

times

for

successful

Author

Part

Ischemia time

May (1981) May (1984) Wei (1986)

Fourth digit Seventh digit Digits

VanderWilde (1991) Chui (1983)

Hand

28 hours/cold 39 hours/cold 84, 86, 94 hours/ warm 54 hours/cold

Hand

33 hours/warm

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Fig. 9. (A–D) This patient amputated all eight fingers in a metal press. He underwent successful replantation of seven of the digits, the last after 39 hours of cold ischemia. (From May JW Jr, Hergrueter CA, Hanson RH. Seven-digit replantation: digit survival after 39 hours cold ischemia. Plast Reconstr Surg 1986:522–3; with permission.)

Bone can be resected on the stump side for the fingers, but not for the thumb where length preservation is more critical, if the amputation level is near the joint on the amputated part. Hand function is compromised with thumb loss proximal to the interphalangeal joint. If the amputation level is through the joint, fusion in the functional position

is required. Primary implant arthroplasty has been described in replantation but with increased risk for infection [28]. Then, retrograde K-wires or intraosseous wires can be placed through the bone on the amputated part (Fig. 12B). Usually there is enough time before the patient is transported to the operating room for

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Fig. 10. Signs of arterial damage should be appreciated, including the telescope, cobweb, and ribbon signs or terminal thrombosis, which would require freshening of the vessel. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

preparation of the amputated part. Alternatively a second team can be recruited to begin the preparation of the stump. The neurovascular structures are isolated, identified, and tagged on the stump side under tourniquet control. Before the arterial anastomosis, the tourniquet is deflated to assess inflow pressure by the proximal vessel spurt [25] (Fig. 13). If the spurt is inadequate, additional proximal vessel shortening is required. Furthermore, in preparing the stump, exposure of the proximal flexor tendon for placement of a core suture is better at this point than after bone fixation. The order for repairing the various structures is individualized. The sequence of repairing the bone, extensor, veins, dorsal skin, artery, nerve, and flexor is preferred by the authors, as it efficiently allows for repairing all the dorsal structures before the volar structures [5] (Table 2). If the warm ischemia time is unusually long, the artery can be repaired earlier. Techniques of osteosynthesis vary: many surgeons prefer cross K-wires, because they are quick and safe (Fig. 14). Union rates have been reported to be better with intraosseous wires, however, either in combination with a K-wire as 90-90 wires [29,30]. Ninety-ninety wires are two intraosseous

Fig. 11. (A,B) Exposure of the neurovascular structures to be labeled on the amputated part. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

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Fig. 12. Once the neurovascular structures of the amputated part have been identified and tagged, they can be carefully retracted for bone shortening. (A) Approximately 5–10 mm of bone shortening is necessary for tension-free vessel repairs and the avoidance of neurovascular defects requiring grafts. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.). (B) Then, retrograde K-wires or intraosseous wires can be placed through the bone on the amputated part.

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Fig. 13. The tourniquet is deflated to assess inflow pressure by the proximal vessel spurt. If the spurt is inadequate, additional vessel shortening is required. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

wires placed perpendicular to each other. Whitney et al found this technique to have lower nonunion rates with replantation procedures because 90-90 wires actually compress the fracture site [30] (Table 3). Another advantage of 90-90 wires is that they are low profile and easy to work around. K-wires can occasionally be awkward and obscure other structures that require repair. After the osteosynthesis, the hand is pronated and the extensor tendon is repaired first (Fig. 15). If the amputation is at the proximal phalanx level it is important to repair the lateral slips, to prevent loss of extension at interphalangeal joints. The dorsal veins are repaired. Next, at least two veins should be repaired in finger replants, especially for replants proximal to the proximal interphalangeal joint. Dorsal veins are preferred because they are larger and don’t interfere with subsequent repair of volar structures (Figs. 16 and 17). Because the veins become smaller and more difficult to identify and repair the more distal the injury, arterial repair may be required first to locate the veins by back bleeding. Once the dorsal structures have been repaired, the dorsal skin is loosely approximated with small-caliber, simple, interrupted sutures.

Table 2 Sequence of repairs in digital replantation Skeletal fixation Extensor tendon Dorsal veins (arteries · 2) Dorsal skin Digital artery Volar nerves Flexor profundus Volar skin

Fig. 14. In performing the bone fixation, many prefer K-wires, which are quick and safe and can be placed in cross or axial configuration. Union rates have been reported to be better with intraosseous wires, however, either in combination with a K-wire as described by Lister or as 90-90 wires. Ninety-ninety wires are two intraosseous wires placed perpendicular to each other, which was found to have lower nonunion rates. (From Goldner RD, Urbaniak JR. Replantation. In Green DP, editor: Green’s operative hand surgery. 4th edition. New York: Churchill Livingstone; 1999. p. 1139–55; with permission.)

The hand is then supinated to repair the injured volar structures. At least one digital artery is repaired. Several anastomotic techniques have been described (Fig. 18). One described technique of microvascular repair involves placing the first two sutures at 10 o’clock and 2 o’clock, then 12 o’clock; the vessel is then turned 180 degrees and additional simple interrupted sutures are placed in sequence. After the completion of the digital artery repairs, the tourniquet is deflated and clamps are removed. The patency of the arterial anastomosis can be assessed with the milk test, capillary refill, and bleeding on pinprick. If arterial flow seems inadequate, one should confirm that the patient has adequate blood pressure and vol-

Table 3 Nonunion rates for various techniques of osteosynthesis with replantation Group

Method (digits)

Nonunion

Required osteotomy

I II III

Crossed K-wire (38) Single K-wire (7) Perpendicular interosseous (8) K+intraosseous (12) K+Cassel (3) Cassel (7)

8 (21%) 1 (14%) 0

5 1 0

1 (8%) 1 (33%) 1 (14%)

1 1 0

IV V VI

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Fig. 15. The hand is pronated, and of the dorsal structures, the extensor is repaired first. If the amputation is at the proximal phalanx level it is important to repair the lateral slips to prevent loss of extension at interphalangeal joints. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

ume, and that the tourniquet actually has been deflated. Bathing the vessel with papaverine, lidocaine, magnesium sulfate, and warm irrigation has been described to counteract the vasospasm [31]. The hand can even be placed in the dependent position to increase inflow pressure with gravity [32]. One should allow at least 10 minutes observation time for resolution of vasospasm before

manipulating the anastomosis. If the milk test is abnormal or if petechiae of the measles sign or ballooning of the sausage sign is encountered, suspect thrombosis and redo the anastomosis [25,33] (Fig. 19). Frequently, in reperforming the anastomosis, further vessel resection is necessary. If the additional vessel resection places the vessel repair under tension, an interposition vein graft is

Fig. 16. At least two veins should be repaired in finger replants, especially for replants proximal to the PIP joint. Dorsal veins are preferred because they are larger and don’t interfere with repair of volar structures later. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

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exposure for the microsurgical repair of the digital arteries and digital nerves (Fig. 23). Common indications for arterial interposition vein grafts include thumb replants, ring avulsions, and segmental artery loss or trauma [35–38]. Potential vein graft harvest sites for distal digital replants include the palmar forearm and wrist. The wrist is preferred by many because the volar wrist veins match the digital vessels [13,39–41]. The leg or contralateral arm may be used to harvest vein grafts for major replants of the hand, forearm, or multiple fingers, as they can be harvested by a second team simultaneously (Fig. 24). Vein grafts must be reversed for arterial interposition because of the valves.

Special considerations and specific cases Thumb replants

Fig. 17. This is an example of a dorsal vein repair with 10-0 nylon sutures in simple, interrupted fashion over the previously repaired extensor tendon.

required. A second artery should be repaired as a safeguard measure. Located superficial and volar to the digital arteries, the digital nerves are coapted next. This can be performed before or after the tourniquet has been deflated. The epineurial nerve repair technique is preferred and can be performed with as few as three sutures (Fig. 20). A nerve conduit or graft is required if one is unable to repair the nerve primarily. Some prefer nerve conduits instead of direct coaptation. Weber et al reported a statistically improved return of sensation using the polyglycolic acid nerve conduits when compared with end-to-end coaptation [34]. Upper extremity nerve graft donors include the medial antebrachial and posterior interosseous nerves. Alternatively, a vein graft can be used for small defects of 2 cm or less (Fig. 21). At this point, the flexor tendon is repaired, tying the previously placed proximal and distal core sutures (Fig. 22). Performing the tendon repair later permits finger extension, giving better

In the thumb, the ulnar digital artery is usually of larger caliber than the radial digital artery [42,43]. Arterial revascularization in thumb replantation therefore is more reliable when based on the ulnar digital artery. This vessel is difficult to expose for the microsurgery, however, and requires extreme arm pronation or supination. An arterial interposition vein graft from the radial artery in the anatomic snuffbox to the distal end of the ulnar digital artery in the amputated thumb helps avoid the cumbersome position of extreme rotation. Alternatively, the digital artery repair could be performed before the osteosynthesis. Care certainly must be taken to prevent disrupting the anastomosis during the bony fixation if this method is chosen [32,42,43] (Figs. 25 and 26). When the thumb has been amputated at or near the MCP joint and the proximal ulnar digital artery has retracted and is difficult to expose, a vein graft can be used from the ulnar digital artery distally to the radial artery in the snuffbox, end to side. In using this vein graft to radial artery technique for replantation of the thumb, retrograde K-wires are placed first into the bone on the amputated part. Then core sutures are placed in the proximal and distal ends of the flexor pollicis longus (FPL) tendon. The digital nerves are labeled with long sutures for easier identification later. A subcutaneous tunnel is created from the ulnar aspect of the thumb base to the snuffbox. The radial artery is exposed in the snuffbox and double pott’s ties are placed on the radial artery proximally and

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Fig. 18. This is a well accepted technique that involves placing the first two sutures at 10 o’clock and 2 o’clock, then 12 o’clock, then the vessel is turned 180 degrees and additional simple, interrupted sutures are placed in sequence. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

Fig. 19. If petechiae of the measles sign or if ballooning of the sausage sign is encountered, suspect thrombosis and redo anastomosis. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

distally in preparation for end-to-side anastomosis of the vein graft to the radial artery. The vein graft is first anastomosed end-to-end to the ulnar digital artery with the microscope. Again this provides much better exposure for the microanastomosis of the ulnar aspect digital artery to the thumb. The vein graft is then pulled through the subcutaneous tunnel to the radial artery in the snuffbox. The digital nerves also can be repaired at this point with better exposure. The osteosynthesis is carefully performed by passing the previously placed K-wires retrograde through the proximal bone. At this point the extensor tendon and dorsal veins are repaired. The vein graft is then repaired end to side to the radial artery in the snuffbox (Fig. 26). If the amputation level is distal to the MCP joint and the proximal end of the ulnar aspect digital artery is well exposed, a primary arterial anastomosis can sometimes be performed without

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Fig. 20. Then, the digital nerves are coapted. This can be performed after the tourniquet has been deflated. Of the different digital nerve repairs, the epineurial technique is preferred and can be performed with as few as three sutures. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

the need for a graft. A technique that has been described to optimize exposure of the ulnar digital artery during the microanastomosis involves performing the microanastomosis before the osteosynthesis [44,45] (Figs. 27 and 28). The Kwires are placed retrograde through the distal amputated part first. The ulnar digital artery and nerve are then repaired with the hand in supination that provides a better angle for the microscope and exposure for the anastomosis. The bone ends are then aligned and the osteosynthesis is completed carefully. The digital artery clamps are left in place until the extensor tendon and dorsal veins are repaired. Finally, the flexor core sutures are carefully tied and the skin loosely approximated.

b Fig. 21. This is an example of a digital artery repair on the left and digital nerve repair superimposed over digital artery repair on the right. Notice the flexor digitorum profundus tendon core sutures have not yet been tied, which allows for finger extension and better exposure of neurovascular structures.

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Fig. 22. At this point, the flexor tendon is repaired, tying the previously placed proximal and distal core sutures. (From Callico CG. Replantation and revascularization of the upper extremity. In May JW, Littler JW, editors: McCarthy Plastic Surgery, Volume 7. The Hand. Philadelphia: WB Saunders Company; 1990; with permission.)

Multiple finger replantation

Fig. 23. This is the same finger after tying of the flexor tendon core sutures, bleeding on pinprick.

In multiple finger replantation, the finger with the best chance for successful replantation, best expected recovery, and contribution to function should be repaired first. If all the fingers are injured at the same level and with the same chance for success, the authors prefer to repair the middle, then index, then ring, and finally the small finger. If the index finger is stiff or insensate, the patient will bypass this to use the middle finger. When all the fingers are stiff, the index finger can actually impede the function and opposition of the other fingers to the thumb (Fig. 29). Because it is essential to minimize ischemia time with multiple digit replantations, each finger is replanted separately. The amputated fingers should be brought to the operating room as soon as possible, where the digital vessels, nerves, and tendons can be identified and tagged with sutures or clips, to save time and minimize ischemia. The order for repairs can be improvised with multiple replantations. Initially, the osteosynthesis, extensor tendon, one dorsal vein, and one digital artery can be repaired for each finger to minimize overall ischemia time.

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Fig. 24. (A,B) This is a vein graft interposing this arterial defect between the two forceps. Notice the size match with this vein graft harvested from the palmar forearm.

Another dorsal vein, the digital nerves, and the flexor tendon core sutures can be repaired later, once the blood flow to the fingers has been reestablished.

Major replants

Fig. 25. First, the vein graft is repaired to the distal ulnar artery. Then the vein graft is pulled through a subcutaneous tunnel to the snuffbox and repaired endto-side to radial artery. (From Goldner RD, Urbaniak JR. Replantation. In Green DP, editor: Green’s operative hand surgery. 4th edition. New York: Churchill Livingstone; 1999. p. 1139–55; with permission.)

Upper extremity replants The order of the replant procedure is modified for major replantations of the hand and upper extremity. Early use of shunting has been described to minimize muscle ischemia time [15,16,32]. It is critical to minimize warm ischemia time to less than 4 hours to avoid muscle necrosis. Intravenous tubing or carotid shunts can be used to infuse and return blood to and from the amputated part (Fig. 30). Fasciotomies are required with major limb replantation and can be performed during the shunting reperfusion to save

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Fig. 26. (A–D) This patient nearly amputated his thumb in a saw. The distal thumb hangs by a dorsal skin bridge. The neurovascular structures were tagged; the flexor pollicis longus tendon core sutures were placed proximally and distally. K-wires were placed in the retrograde fashion distally. The distal ulnar digital artery was repaired to the vein graft with excellent exposure. Then the osteosynthesis was performed, reducing the fracture line and carefully passing the K-wires in retrograde fashion into the proximal bone. Finally the vein graft is tunneled subcutaneously to the snuffbox, where it is repaired end-to-side to the radial artery.

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time. Bone shortening may avoid the need for nerve and vein grafting and allow for soft tissue closure over the repairs. With humeral level replants, the brachial artery and brachial venae commitante are repaired. The ulnar, median, and radial nerves are repaired. The skin is lightly reapproximated. Skin grafts are usually required for definitive closure. These upper extremity replants may require several operating room debridements at 48-hour intervals to remove devascularized, nonviable muscle. Amputations at this level often denervate the biceps muscles and later require latissimus or pectoralis muscle transfers to provide for active elbow flexion. Fig. 27. A technique that has been described to optimize exposure of the ulnar aspect digital artery during the microanastomosis involves performing the microanastomosis before the osteosynthesis. (From Caffee HH. Improved exposure for arterial repair in thumb replantation. The Journal of Hand Surgery 1985;10A(s):416; with permission.)

Hand replants Again, vessels, nerves, and tendons are identified and tagged and K-wires are placed in the

Fig. 28. (A–D) This patient amputated his thumb with a rope in a boating accident. This replantation actually involved repairs at two levels. First, K-wires were placed in the amputated part. Repairs on the amputated part were performed first. Two dorsal veins and the ulnar aspect digital artery and nerve were repaired in the amputated part with the microscope on the back table. Then, the ulnar aspect digital artery of the amputated part was repaired to the proximal end of the ulnar aspect digital artery on the stump side with the microscope, before osteosynthesis to avoid the struggle for exposure often requiring extreme hand pronation. Then the digital nerve was repaired. Then the osteosynthesis was performed carefully passing the K-wires distal-to-proximal. The amputated part, extensor pollicis longus tendon, and two dorsal veins were repaired to the stump, before removal of the digital artery clamps proximal and distal to the microanastomosis. Leaving the clamps maintains hemostatic control and better exposure for the vein repairs. Finally, the flexor pollicis longus (FPL) tendon core sutures are carefully tied and the skin is loosely approximated.

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Fig. 28 (continued )

retrograde fashion into the amputated part in the operating room before the patient is transported from the emergency room (Fig. 31). Similarly, the ischemia time can be minimized by shunting, during which fasciotomies can be performed if necessary. The most time-consuming part of a hand replantation is the tendon repairs. The exposure of the proximal flexor tendon ends can be optimized by placing a longitudinal incision up the mid portion of the forearm. Also, tagging of the proximal and distal flexor tendon ends before the osteosynthesis can facilitate the repair of the flexor tendons later. It is important to understand the stacked array of the flexor tendons with the middle and ring flexor digitorum sublimis tendon (FDP) volar to the index and small finger superficialis flexors (Fig. 32). Replantation of hand amputations at the wrist level may necessitate bone shortening (eg, proximal row carpectomy) to avoid nerve and vein grafts. Overall, the ulnar and radial arteries, four veins, median, ulnar, and superficial radial nerves are repaired and many tendons as possible. At least the four flexor digitorum profundus tendons, flexor carpi radialis, flexor carpi ulnaris, four extensor digiti communis tendons, extensor carpi ulnaris, extensor carpi radialis, extensor pollicis longus, and flexor pollicis longus should be performed. In

general, replantations at this level can achieve very good results.

Cross hand transfer A special circumstance may call for considering a cross hand transfer (ie, bilateral hand upper extremity crush avulsion amputations with significant soft tissue or bone destruction precluding bilateral ipsilateral replantation) [46–48]. The patient in Fig. 33 had a brachial plexus injury rendering his right hand functionless [48] (Fig. 34). Accordingly, this right hand was electively transferred to the contralateral side, which had a thumb but was devoid of all four fingers. This elective cross partial hand transfer was performed at the level of the carpometacarpal joint with intraosseous wires (excluding the thumb). This was the first elective partial cross hand transfer (excluding the thumb) reported in the literature. He went on to attain good functional use of this hand following transfer.

Postoperative care Postoperative care has traditionally included warming the patient’s room to avoid vasospasm

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and positioning the extremity at the heart level to minimize edema but not compromise arterial or venous flow. Anticoagulation is generally recommended. Several investigators recommend the routine use of aspirin and dextran with replantation, [5,49,50] and therapeutic heparin for crush avulsion injuries [32,49]. Depending on the mechanism of injury, antibiotics are considered. Patients are encouraged to abstain from smoking and caffeine use for 1 month [51,52]. The replanted part is monitored by checking color, capillary refill, tissue turgor, and temperature. Sympathetic blocks have been described for high-risk replantations after crush avulsion injuries [25]. Arterial insufficiency is the most common cause for replantation failure, accounting for approximately 60% of failures in two studies

[5,49]. Arterial insufficiency is suggested by decreased capillary refill, tissue turgor, and temperature. Treatment of arterial insufficiency includes removal of potentially constricting dressings and tight sutures, decreasing extremity elevation to promote inflow with gravity, and sympathetic blockade. Finally, early operative intervention can be considered if there is no improvement with the above measures. Reexploration to correct arterial insufficiency has been reported to be successful in 50% of return visits [5,49]. Venous congestion is a less common cause for replantation failure [5,49]. Venous congestion should be suspected with rapid capillary refill, increased tissue turgor, or bleeding of wound edges [49]. Treatment of venous congestion includes removal of tight dressings and

Fig. 29. (A–G ) This 50-year-old man amputated all four of his fingers in a printing press. Each finger is replanted separately to minimize warm ischemia time. Two dorsal veins and one digital artery were repaired for each finger in the dorsal and volar sequence described by O’Brien. The fingers were replanted in order of functional importance. The authors repaired this patient’s index finger last, because the amputation level was to the proximal interphalangeal level and would be less functional. All four replants survived: He quickly regained the ability to write. With tenolysis procedure and correctional osteotomy of the index finger, he went on to regain >50% total active motion (TAM). He even created this glove that he uses to help lift weights.

Fig. 29 (continued )

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B.J. Wilhelmi et al / Hand Clin 19 (2003) 89–120 Table 4 Survival rates for replantations Author

Number Survival rate

Tamai (1982) Kleinert (1980) Urbaniak (1979) Sixth People’s Hospital (1975)

157 347 107 320

80% 70% 82% 54%

cannot be repaired and the patient refuses leeches [53]. Finally, operative revision can be considered, but is less successful than reexploration for arterial insufficiency.

Outcomes

Fig. 29 (continued )

sutures and increasing elevation to promote venous drainage with gravity. Leeches are also effective at treating venous congestion in replantation. Nail plate removal and application of a heparin soaked sponge to the nail bed has been described for distal replantations when a vein

Overall success rates for replantation approach 80%. In reviewing large volume retrospective reports, these success rates range from 54% in China’s Sixth People’s Hospital to 82% in North Carolina [54–57] (Table 4). Overall, success rates are significantly higher for replantation of guillotine (77%) versus crush (49%) amputations [5,49]. In general, approximately 50% achieve two-point discrimination (2 PD) less than 10 mm [58–62]. Seventy percent of Tamai’s 228 replants achieved 2 PD <15 mm,

Fig. 30. (A–G) This 40-year-old man amputated his left arm in a rollover car accident. His amputated arm was found in a ditch, 30 feet in front of him and his upside-down car. The arm was brought to the operating room before the patient arrived; it was extensively irrigated and structures to be repaired were identified and labeled. The humerus was shortened enough to allow for skin approximation over the repairs. Then osteosynthesis was performed with a 4.0 compression plate. Next, the use of carotid shunts to and from the amputated part minimized the total ischemia time to 3 hours. During this shunting reperfusion, forearm and hand fasciotomies were performed. Then the brachial artery was repaired with a reversed saphenous vein graft. The brachial venae commitante were repaired. Then the median, ulnar, and radial nerves were coapted. At 48 hours and several times after that he returned to the operating room for debridement of portion of the triceps, distal deltoid, and biceps muscles and skin edges. Finally, at 2 months postoperatively, he did not have any open areas or evidence of nerve regeneration.

Fig. 30 (continued )

Fig. 31. (A–D) This 63-year-old woman accidentally amputated her left hand while helping cut wood with a radial saw for her family fence-making business. The amputation was at the distal carpal row. K-wires were used for osteosynthesis. Before the osteosynthesis, the neurovascular structures were identified and labeled, together with the tendons. Overall, the ulnar and radial arteries, four veins, median, ulnar and superficial radial nerves, and 18 tendons were repaired. Postoperatively, despite her advanced age and less than optimal participation with therapy she had some return of function.

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Fig. 31 (continued )

whereas 65% of Larsen’s 142 replants attained 2 PD <10 mm [57,58]. In general, younger patients with distal guillotine amputations experienced better return of sensation. Several studies have determined the average replant to achieve 50% of normal function (ie, 50% total active motion and 50% grip strength) [60,63– 65]. Return of function was worse for zone II injuries and for patients of advanced age. Russell published the largest review of major limb replantations and found 11/24 achieved >50% total active motion and 19/24 achieved protective sensation, and 22/24 patients were satisfied with the function and appearance of their replanted part [10]. Jupiter showed the function of replanted digits could be significantly improved with tenolysis procedures [66]. In his review, the total active motion of 37 replanted digits was significantly improved (P < 0.001) with tenolysis and no digits were lost [66]. The patient in Fig. 34 underwent replantation

of the middle and ring fingers after amputation in a log splitter (Fig. 34). He went on to experience loss of active and passive flexion. To improve the socially unacceptable posture of his permanently extended middle finger, he required flexor tenolysis, extensor tenolysis, and capsulotomy procedures. A median nerve catheter was used to provide the patient with better pain control postoperatively, for immediate active range of motion exercises. Postoperatively, he had full active range of motion at 6 weeks.

Summary With the evolution of surgical techniques and scientific technology, replantation has become more refined, establishing specific indications for replantation, rituals for preparation, efficient techniques to ultimately minimize ischemia times,

Fig. 32. A simple method of demonstrating the arrangement of sublimis tendons at wrist with the middle and ring fingers volar to the index and small fingers. (
Frank Netter. Clinical Symposia, Volume 21(3). Summit, NJ: Ciba Pharmaceuticals; 1969. p. 88).

B.J. Wilhelmi et al / Hand Clin 19 (2003) 89–120 113

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Fig. 33. (A) This patient had a brachial plexus injury rendering his right hand functionless. Accordingly, the right hand was electively transferred to the contralateral side, which had a thumb but was devoid of all your fingers and metacarpals. (B,C ) This elective cross hand transfer was performed at the level of the carpal metacarpal joint with intraosseous wires. (D–F ) This patient went on to attain good functional use of this hand following transfer.

improved survival rates, guidelines for postoperative care, strategies for treating complications, and goals for outcomes. Patient satisfaction hinges on their level of expectation as defined and explained in the preoperative discussion and informed consent. Studies have demonstrated patients can be expected to achieve 50%

function and 50% sensation of the replanted part. Initially all that was amputated was replanted, as surgeons adopted the philosophy of George C. Ross (1843–1892): ‘‘Any fool can cut off an arm or leg but it takes a surgeon to save one.’’ Forty years after the first replant (1962–2002), however, we recognize the ultimate

B.J. Wilhelmi et al / Hand Clin 19 (2003) 89–120

Fig. 33 (continued )

goal: not merely to preserve all living tissue through nonselective replantation, but rather to preserve one’s quality of life by improving their function and appearance. This objective to care

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Fig. 34. (A–K ) This patient underwent replantation of the middle and ring fingers after amputation in a log splitter. He went on to experience loss of active and passive flexion. To improve the socially unacceptable posture of his middle finger, he required flexor tenolysis, extensor tenolysis, and capsulotomy procedures. A median nerve catheter was used to provide the patient with better pain control postoperatively, for immediate active range of motion exercises. Postoperatively, he had full active range of motion at 6 weeks.

for the patient with the intent to optimize function and appearance is important not only to the replantation of amputations but to all mutilated hand injuries.

Fig. 34 (continued )

Fig. 34 (continued )

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Fig. 34 (continued )

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