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Replantation:
Hey Doc, can you putmy finger back on ?
Amy F Kells MD PhD
Division of Plastic & Reconstructive
Surgery
Washington University, St Louis
October 3, 2014
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Goals of
Replantation Presentation
History of Replantation
Pre & Post Operative Management
Surgical Technique and Relevant AnatomyResults of Digital Replantation
Costs to Society
Indications & ContraindicationsThumb Replantations: a special case
Replantations: the Horizon
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Replantation History
First replantation performed onMay 23, 1962 byDr Ronald Malt at MGH
12 year boy who amputated hisarm in train accident
The amputation level was thehumeral neck
A steel rod was used for boney
fixationBrachial artery and 2 veins andthe median, ulnar and radialnerves were repaired
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Replantation History
Dr Malt performed anotherreplant in 1964 andpublished his resultstogether with Dr McKhann in
the September 7th1964issue of Journal of the
American MedicalAssociation.
Later, Dr Malt reported hisfirst patient had somerecovery of function afterwrist arthrodesis and tendontransfers.
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Replantation History: First Digital Replant
The first successful digitalreplantation was performedon July 27, 1965 by
Drs Komatsu and Tamai.Department ofOrthopedic SurgeryNara Medical CollegeNara, Japan
Published 1968 in Plasticand ReconstructiveMicrosurgery, 42: 374-77
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First Digital Replantation
28 y/o male cut off leftthumb working w/ steelcutting machine
Sent to hospital 30 minafter injury
Severed thumb dropped
on ground once in route
Relatively clean cutthrough MCP joint w/minimal tissue damage
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First Digital Replantation
Brachial plexus block usedfor left arm
Wounds washed and
debridedVolar digital arterycannulated w/ 0.5mm diam.Canula and flushed w/heparin diluted in low
molecular weight dextranCartilage of MCP removedand joint fused w/ 2 K-wiresin position of abduction
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First Digital Replantation
Using 10x-16x magnification,2 volar arteries and 2 dorsalveins were sutured end toend w/ 7-0 braided silk and8-0 monofilament nylon
Nerve repair postponed toavoid trauma to newanastamosis
Extensor tendon repaired
Flexor tendon postponeddue to zone II injury level
The thumb became pinkimmediately, and veins filled
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First Digital Replantation
Complete OR time: 41/2hrs
Ischemic time: 3 hrs
Sl edema developed POD
#2, but resolved in 7 daysSympathetic block wasperformed daily for 18 days
Heparin 200mg/dayintramuscularly and lowmolecular weight dextran
500cc/day were given for 9days
Pt d/cd POD # 40
Returned to work after 4 mos
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First Digital Replantation
POD #200: slight atrophyand loss of sensation buthas pinch
At 2 yrs and 5 mos s/preplantation pt has regainedsome ulnar sided sensation
A moderate flexioncontracture is present inthe IP joint, but thisposition is very useful tohim.
Little has changed in the technique from this first description of a digital replant
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Digital Replantation: Indications
Initial tendency to replant every severedfingerResults of studies published in 1980srevealed about 50% return of function in
replanted digits, worse w/ zone II injuriesToday the emphasis is not how to replant adigit, but how to make it functionalSurgical success previously judged on
viability alone, now focuses on functionaloutcomeThis has led to a refinement of indications fordigital replantation
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Replantation: IndicationsGreens Operative Hand Surgery
Thumb
Multiple digits
Single digit distalto FDS insertion
Partial hand-palm
Almost any part in
childWrist or forearm
Elbow & above w/sharp amputation
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Replantation: ContraindicationsGreens Operative Hand Surgery
Severely crushed or mangled
parts
Multiple level
Single digits proximal to FDSinsertion-especiallyindex& little fingers
Prolonged warm ischemia > 12 hrs
Associated serious
injuries/diseasesArteriosclerotic disease
Mental instability
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Initial ER Management
Do not clamp or tie off any bleedingvessels
Direct pressure with a bulky dressing
will control any digital bleeding duringtransport
Hydrate patient with IV Fluids, keep
NPOTetanus, Antibiotic prophylaxis & ASA
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Initial ER Management: Replant ????
STEP 1: Assess medical status for lengthyreplantation procedure
Other injuries
Cardiac status
Step 2: Examine amputated part
Step 3: Have frank discussion with patient
need for blood, possible anticoag, ICU stay
commitment to rehab
length of time out of work
potential outcome.stiff, painful finger
NEED TO QUIT SMOKING !!!
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Aesthetic Plastic Surgery 2002;26:477-482
Smoking detrimental via 2 pathways: Nicotine causes vasoconstriction
Relative hypoxia of carboxy-hemoglobin causes increasedfibrinogen & RBC aggregationleads to increased bloodviscosity
2 patients, 3 replanted digits, smoked POD#4..
Both patients lost digits on POD #7 & #9
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Initial ER Management :
Preservation of Digit
Management should begin with appropriate handling ofthe amputated digit
Place in moistened gauze in plastic bag on ice
Do not place directly on ice or directly into liquid
X-ray the digit and hand
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Digital Replantation Technique:
Operative Sequence
Locate and tag vessels and nerves
Debride
Shorten and fix the bone
Repair tendons
Anastomose Arteries
Repair NervesAnastomose Veins
Obtain skin coverage
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Digital Replantation Technique:
Debridement & Tagging
2 teams are optimal
The first step is debridement andtagging of vessels and nerves with9-0 nylon
Longitudinal midlateral incisionsprovide the best exposure to neuro-vascular bundles
Assessment of status of digital
arteries is made at this timeRibbon Sign-walldamageRed Line Sign-distal thrombosis
Tag dorsal veins if you see Ribbon Sign Red Line Sign
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Digital Replantation Technique:
Bone Shortening & Fixation
Bone shortening to avoid need forinterposition grafts
5-10mm of bone shortening should beperformed on the amputated part (not on
thumb)
Multiple methods of bone fixation
Most common method is double or single
axial K-wires for middle or distal phalanx
Crossed K-wires for proximal phalanx 1) Simple & Quick2) Less bone exposure
3) Less skeletal mass
4) Easy correction of rotational deformity
Amputation thru joint will require fusion in functional position
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Digital Replantation Technique:
Tendon Repair
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Digital Replantation Technique:
Arterial Assessment
Drop tourniquet andassess inflow
Assess for need ofinterposition vein graftor vessel shift
Freshen ends ofvessels back to pristineintima
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Digital Replantation Technique:
Arterial Anastomosis
Use double micro vessel clip
9-0 nylon sharp point
Place sutures at 10:00 oclock, 12:00
oclock & 2:00 oclock
Flip vessel 1800
Complete front wall
5000u hep bolus prior to clamp release
Remove clips: assess w/ milk test
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Digital Replantation Technique:
Arterial Anastomosis Assessment
If flow seems sluggish.. confirm adequate Pt BP Pt volume status complete tourniquet deflation
Allow at least 10 minutes forvasospasm to resolve Papaverine Lidocaine Warm irrigation
Development of petechiae
or measles sign orballooning of the inflowlimb of the anastomosis,the sausage sign, shouldbe red flag forthrombosis..
revise anastomosis
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Digital Replantation Technique:
Nerve Repair
Can be performed withtourniquet deflated
Freshen ends so that fascicles
are flush with epineurium
Use epineurial repair
Coapt nerves w/ 3 sutures
Autograft can be used for defects
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Digital Replantation Technique:
Venous Anastomosis
Pronate hand
Look for back bleeding
Very helpful to tag at start
of procedure (rememberits hour 6+ under themicroscope!)
Need 2 veins for 1 artery
Use same anastomotictechnique as artery butneed less sutures.
low pressure system
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Digital Replantation Technique:
Getting Out Of The OR
Loose skin closure
Double check vessel positioning to avoidkinking or compression
Full thickness skin graftsVery loose dressing w/ strict elevation
Pulse oximetry monitoring of replanted digit
Dont forget basics!! Maintain blood pressure MAP>70, UOP >70
FLUIDS NEVER PRESSORS
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Digital Replantation:
Postoperative Management
Continuous plexus blockade.3 to 5 days
Continuous pulse oximetry monitoring
Adequate IV hydration.UOP > 50cc/hrWarming blanket
Aspirin, Avoid caffeine, smoking for 5 weeks
Heparin Use full dose drip after anastomotic revision
Strongly consider in crush or avulsion injuries
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Digital Replantation: Results
1983 to 1995 with 2 yrs or > F/U
1018 digital replantations in 552 pts
Successful outcome 92.9% of digits
Type of injury was the most important predictor of outcome
Regular Cigarette smoking resulted in poor immediate survival
Prolonged ischemia ( >9hrs) led to increased poor functional outcome
Injury in the proximal phalanx region resulted in poor ROM
Repairing the FDP distal stump to the FDS proximal stump improved resultscompared to 2 tendon repair and FDP to FDP
Replantation should be carried out even if only one digit is involved.
Injury 2000;31:33-40
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50% Failure Rate with Smokers
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Digital Replantation: Costs to Society
National sampling data basebased on 20% of USHospitals
304 cases of fingerreplantation in U.S. in 1996
Mean LOS 5.5 days
Total charges $20,330
Extrapolated data:
1,153 replantations in US $ 24 million
Journal of Hand Surgery 2000;25A:1038-42
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Digital Replantation: Costs to Society
30 pts w/ amputations of thumb or 2 or more digits proximal to PIPjoint
24 pts successful replantation, 3 failed, 3 primary amputations
Calculable cost greatest for sick leave (46%), operation (26%),ward cost (20%)
Sick leave mean 8.8 mos (replant), 5.3 mos (failed), 4.8 mos (amp)
Replant cost 1.6 times mean annual salary, amputation 0.8 times
Subjective evaluation of 23 parameters of function, cosmesis andquality of life did not disclose any differences between groups
The Question of whether replantation is economically feasible to society remains
Journal of Hand Surgery (British) 1996;21B:576-80
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Thumb Replantation: A Special Case
Thumb provides more than 40% of entire handfunction and replantation should be considered inmost cases
Even avulsion injuries should be considered
Injuries requiring MP fusion can yield good function
Ulnar artery is dominant
Use vein graft to radial artery in snuff boxGive priority in multi digit amputations: usetransposition technique and replant least damageddigit in place of thumb if it is non-replantable
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Hand Fellowship Thanksgiving Replant Feast
4:00 pm Thursday: thumb replant tobe transferred to Bellevue..Patient
arrives 8:00pmOut of OR 5:00 am Friday
10:00 pm Saturday multidigit replantarrives ER.3:00 am out of
OR.no finger suitable
11: 00 pm SundayAhin the clear
11:15 pm.pager goes off
hey Amy, theres a guy who cut
off his thumb and he really wants
us to try to put it back on
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12:00 am Monday Morning in OR
What I thoughtwhat are you
thinking Rob?What I said.. Hmm
looks like a pretty badinjury, you sure about
this Rob?OK then.Hope you have music ?
54 y/o male drinking while using circular saw
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Amputated Thumb
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Venous Graft for Arterial Anastomosis
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8:00 am Monday Morning
th f ll
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one month follow-up
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My favorite Replant
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My Favorite Replant
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After the Hospital
Chapel Wedding POD#4
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Back to work Full Duty
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Thumb Amputation Options: Toe Transfer
16 pts s/p transfer vs 5 amputations
at MCP levelMean f/u ( 3-13 yr )
Functional testing showed minimaldifference compared to normal side
No significant lower extremitymorbidity from donor site
Transfer pts also showed improvedvitality and emotional domainscompared to amputation pts
Journal of Hand Surgery 2000; 25A:651-8
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Digital Replantation: The Horizon
24 hands have been transplanted onto 18 recipients
Initial results have been promising
Hand transplantation may be an important procedure forfunctional restoration of upper limbs
However, the ethical aspects of chronic immunosuppression for a
non-life threatening condition is an ongoing debateThe future of hand transplants lies in the development of lesstoxic immunosuppressive drugs and/or safer methods oftolerance induction
Acta Orthopaedica 2005; 76(1): 14-27
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Digital Replantation: Bibliography
Wilhelmi BJ, Lee WP, Pagensteert GI,May JW. Replantation in the mutilatedhand. Hand Clin. 2003;19(1):89-120
Morrison WA and McCombe D. DigitalReplantation. Hand Clin. 2007;23(1):1-12
Green DP, Hotchkiss RN, Pederson WC,
Wolfe SW. Greens Operative HandSurgery 5thEdition.Philadelphia: Elsevier, 2005