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Twenty-three years of replantations
SESSION7 More than ten variants of the flaps have been used for reconstruction of extensive defects of the upper extremities. However in most cases the following types of flaps have been used: radial forearm flaps, digital and metacarpal island flaps, fibularosteo-septo-cutaneus flaps, ilium bone flap, gracilis and latissimus dorsi muscle flaps. The radial forearm flap had been used in some cases as a composite flap, including vascularized tendon graft, nerve, fascial tissue and muscular components. We worked out a method of increasing the size of the radial forearm flap based on the septal construction of the blood supply of the flap. In two cases we used the radial forearm flap for creation of a thumb with good functional result. In some cases free vascular fibular epiphysial bone flap was used for radiocarpal and shoulder joint formation. The reconstruction had been used in conjunction with the Ilizarov device. Muscle flaps were usually used for restoration of hand function.
Replantation of degloved skin: A feasible solution R. Adani, C. Castagnetti, L. Castagnini, R. Busa, A. Caroli
Modena, Italy Degloving injury of the hand is still one of the most difficult problems in reconstructive surgery. Generally the pure degloving injury leaves the underlying anatomical structures (tendons, bones and joints) intact. The aim of treatment should be coverage with pliable, sensitive and cosmetically similar skin. Various surgical methods (island or free flaps) have been adopted in the past years without solving the problems entirely. In 1981, Watson and McGregor suggested that "with increasing experience in microsurgical techniques it may not be long before replacement of degloved skin becomes a feasible solution of this difficult problem".
35 damaged irreversibly by the trauma. Coverage obtained in this way offers the best cosmetic results and allows early mobilization and good recovery of joint motion. Reestablishing sensibility is more difficult. It is not always possible to suture the digital nerves damaged by the injury, and even when neurorraphy is performed the results are often unsatisfactory.
Twenty-three years of replantations G. A. Brunelli, A. Vigasio, G. R. Brunelli
Brescia, Italy After the first replantation in Italy which we performed in Brescia in 1973, we have done more than 800 replantations for total or sub-total amputations. By experience we have now restricted indications and improved our technique and have obtained an increased average survival and number of good results. General indications have slightly changed since the beginning: old age is no longer a contraindication since biological age is more important. Time of ischaemia is very important in macro replantations: if it has been longer than 6 hours at room temperature, operation is generally not performed. In selected cases muscle excision may diminish the risks of ischaemia as well as those due to tissue crushing. Fingers can always be replanted even after 24 hours. The thumb has always to be replanted using neurovascular pedicles from neighbouring fingers if necessary. If thumb replantation is not possible we immediately do pollicization of the index finger or replantation of another amputated finger in place of the thumb. We often use parts of amputated fingers, which cannot be replanted, to improve replantation. Isolated amputations of the index (and ring finger) in the adult is not an indication unless the patient is a pianist or a top-model. In distal digital amputations we perform replantation in the thumb but in long fingers we use distal replantations or, alternatively, different types of flaps. As regards big segments, in selected cases with short ischaemia time we will do replantation at shoulder, arm and elbow levels. Especially at the elbow we have obtained very satisfying results for the patients.
Objective We report our results (cosmetic appearance, ROM, recovery of sensibility) in the treatment of degloved hand and fingers by microsurgical replantation of the avulsed skin.
High arm-level replantations in children: late results
Methods
M. Solinc
Between 1988 and 1995, nine patients with degloving injuries of the hand and fingers were treated by replantation of the degloved skin layer. The injury involved the thumb in three patients, the ring finger ~n three, the little finger in one and multiple fingers in two patients. Successful complete revascularization was obtained in eight patients. In one patient with multiple degloving injury of the finger, revascularization was achieved only in the middle finger. Deferred thumb reconstruction was carried out by a free flap from the foot.
Ljubljana, Slovenia
Results With a mean follow-up of 28 months, good cosmetic appearance and protective-to-light touch sensation was obtained in all cases with excellent recovery of range of motion of digital joints.
Conclusions Revascularization of the degloved skin does represent the best solution and must be attempted early, when the vessels are not
We evaluated three children 3 to 5 years of age who underwent major limb replantation between 1982 and 1986 at the University department of plastic surgery in Ljubljana. All injuries were high arm-level amputations, two of them caused by a driving belt and one by a train. Replantation was performed 3 to 5 hours after the amputation. The operation took 5 to 6 hours. Bone shortening was the rule (mean 5 cm) and plates were used for fixation, in all cases we sutured the brachial artery, three veins and three main nerves. No vein or nerve grafts were required. The skin was closed primarily. All three replantations were successful. In the postoperative treatment dynamic splintage, physiotherapy and compresive bandage were used. Patients later underwent additional procedures - functional tendon and muscle transfer (3•3 cases). The subjective evaluation revealed that all the patients were satisfied by the appearance of the replanted limb and they were
Replantation of degloved skin: A feasible solution R. Adani, C. Castagnetti, L. Castagnini, R. Busa, A. Caroli
Modena, Italy Degloving injury of the hand is still one of the most difficult problems in reconstructive surgery. Generally the pure degloving injury leaves the underlying anatomical structures (tendons, bones and joints) intact. The aim of treatment should be coverage with pliable, sensitive and cosmetically similar skin. Various surgical methods (island or free flaps) have been adopted in the past years without solving the problems entirely. In 1981, Watson and McGregor suggested that "with increasing experience in microsurgical techniques it may not be long before replacement of degloved skin becomes a feasible solution of this difficult problem".
35 damaged irreversibly by the trauma. Coverage obtained in this way offers the best cosmetic results and allows early mobilization and good recovery of joint motion. Reestablishing sensibility is more difficult. It is not always possible to suture the digital nerves damaged by the injury, and even when neurorraphy is performed the results are often unsatisfactory.
Twenty-three years of replantations G. A. Brunelli, A. Vigasio, G. R. Brunelli
Brescia, Italy After the first replantation in Italy which we performed in Brescia in 1973, we have done more than 800 replantations for total or sub-total amputations. By experience we have now restricted indications and improved our technique and have obtained an increased average survival and number of good results. General indications have slightly changed since the beginning: old age is no longer a contraindication since biological age is more important. Time of ischaemia is very important in macro replantations: if it has been longer than 6 hours at room temperature, operation is generally not performed. In selected cases muscle excision may diminish the risks of ischaemia as well as those due to tissue crushing. Fingers can always be replanted even after 24 hours. The thumb has always to be replanted using neurovascular pedicles from neighbouring fingers if necessary. If thumb replantation is not possible we immediately do pollicization of the index finger or replantation of another amputated finger in place of the thumb. We often use parts of amputated fingers, which cannot be replanted, to improve replantation. Isolated amputations of the index (and ring finger) in the adult is not an indication unless the patient is a pianist or a top-model. In distal digital amputations we perform replantation in the thumb but in long fingers we use distal replantations or, alternatively, different types of flaps. As regards big segments, in selected cases with short ischaemia time we will do replantation at shoulder, arm and elbow levels. Especially at the elbow we have obtained very satisfying results for the patients.
Objective We report our results (cosmetic appearance, ROM, recovery of sensibility) in the treatment of degloved hand and fingers by microsurgical replantation of the avulsed skin.
High arm-level replantations in children: late results
Methods
M. Solinc
Between 1988 and 1995, nine patients with degloving injuries of the hand and fingers were treated by replantation of the degloved skin layer. The injury involved the thumb in three patients, the ring finger ~n three, the little finger in one and multiple fingers in two patients. Successful complete revascularization was obtained in eight patients. In one patient with multiple degloving injury of the finger, revascularization was achieved only in the middle finger. Deferred thumb reconstruction was carried out by a free flap from the foot.
Ljubljana, Slovenia
Results With a mean follow-up of 28 months, good cosmetic appearance and protective-to-light touch sensation was obtained in all cases with excellent recovery of range of motion of digital joints.
Conclusions Revascularization of the degloved skin does represent the best solution and must be attempted early, when the vessels are not
We evaluated three children 3 to 5 years of age who underwent major limb replantation between 1982 and 1986 at the University department of plastic surgery in Ljubljana. All injuries were high arm-level amputations, two of them caused by a driving belt and one by a train. Replantation was performed 3 to 5 hours after the amputation. The operation took 5 to 6 hours. Bone shortening was the rule (mean 5 cm) and plates were used for fixation, in all cases we sutured the brachial artery, three veins and three main nerves. No vein or nerve grafts were required. The skin was closed primarily. All three replantations were successful. In the postoperative treatment dynamic splintage, physiotherapy and compresive bandage were used. Patients later underwent additional procedures - functional tendon and muscle transfer (3•3 cases). The subjective evaluation revealed that all the patients were satisfied by the appearance of the replanted limb and they were