Replantation

Author: Derek Moore

Topic updated on 05/03/13 9:55pm

Introduction

Indications
- thumb
- multiple digits
- almost all parts in children
- wrist or forearm
- elbow and above elbow
- individual digits distal to insertion of FDS
Contraindications
- single digit proximal to FDS insertion (Zone II)
- mangled parts
- multiple levels
- other serious medical conditions
- prolonged ischemia time
- self-inflicted wound
- mentally unstable patients

Treatment

Transport of amputated tissue
- keep wrapped in moist gauze in lactate ringers solution
- place in sealed plastic bag and place on ice
Time to replantation
- proximal to carpus
  - warm ischemia time < 6 hours
  - cold ischemia time < 12 hours
- distal to carpus (digit)
  - warm ischemia time < 12 hours
  - cold ischemia time < 24 hours

Techniques

Replantation
- sequence of repair (befanvs)
  1. bone
  2. extensor tendons
  3. flexor tendons
  4. arteries
  5. nerves
  6. veins
  7. skin
Finger order
- thumb, long, ring, small, index
For multiple amputations structure-by-structure sequence is most efficient
- digit-by-digit sequence takes the most time

Postoperative Care

Environment
- keep patient in warm room (80°F)
- avoid caffeine, chocolate, and nicotine
Replant monitoring
- skin temperture most reliable
  - concerning changes include a > 2° drop in skin temp in less than one hour or a temperture below 30° celcius
- pulse oximetry
  - < 94% indicates potential vascular compromise
Anticoagulation
- adequate hydration
- medications (aspirin, dipyridamile, low-molecular weight dextram, heparin)
Arterial Insufficiency
- treat with
  - release constricitng bandages
  - place extremity in dependent position
  - consider heparinization
  - consider stellate ganglion blockade
  - early surgical exploration if previous measures unsuccessful
- thrombosis secondary to vasospasm is most common cause of early replant failure
Venous congestion
- treatment
  - elevate extremity
  - leech appliation
    - releases Hirudin (powerful anticoagulant)
    - Aeromonos hydrophila infection can occur (prophylax with Bacrtim or ciprofloxacin)
  - heparin soaked pledgets if leeches not available

Complications

Infection
Cold intolerence
Stiffness
- replanted digits have 50% of total motion
- tenolysis is most common secondary surgery
Myoglobinuria
- caused by muscle necrosis in larger replants (forearm and arm)
- can lead to renal failure and be fatal
Reperfusion injury
- mechanism thought to be related to ischemia-induced hypoxanthine conversion to xanthine
- allopurinol is the best adjunctive therapy agent to decrease xanthine production

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Qbank (10 Questions)

TAG

(OBQ11.166) A 25-year-old right-hand dominant construction worker suffers an industrial injury as seen below. He is hemodynamically stable and his only injury is to the limb below. In terms of replantation of the affected limb, which of the following is true? Topic

Review Topic

FIGURES: A

1. Transpositional microsurgery offers the best results
2. Replantation is contraindicated as the injury is through flexor zone II
3. Replantation is contraindicated because of the extent of injury
4. Heterotopic transplantation would offer the best function
5. Anatomic replantation of hand offers the best results

PREFERRED RESPONSE ▶

DISCUSSION: The clinical scenario and images depict a through the palm amputation with the digits intact. The injury is a clean amputation with minimal avulsion. Thus, anatomic replantation of the entire hand is indicated. Digit transposition refers to using the salvageable digits and replanting them on the functionally important positions in the hand. Transpositional replantation is not indicated in the above scenario and would be more appropriate for a multidigit amputation as shown in Illustration A.

Soucacos et al reviewed their results of transpositional digital microsurgery in 34 patients. They found that transposition of a digit to the most functional part of the hand lead to a 2-point discrimination of 10-14mm in transposed digits and equivalent functionality of transposed digits with anatomically replanted digits.

Schwabegger et al presented a case series of 13 patients with multiple digit amputations. The primary goal of surgery was function and secondly, cosmesis. They found the results of transpositional replantation similar to conventional replantation.

Illustrations: A

REFERENCES:

1. Soucacos PN, Beris AE, Malizos KN, Vlastou C, Soucacos PK, Georgoulis AD. Transpositional microsurgery in multiple digital amputations. Microsurgery. 1994;15(7):469-73. PMID:7968476 (Link to Abstract)

2. Schwabegger AH, Harpf C, Rumer A, Hussl H, Anderl H, Ninkovic MM. Transpositional replantation of digits. Case reports. Scand J Plast Reconstr Surg Hand Surg. 1999 Jun;33(2):243-9. PMID:10450584 (Link to Abstract)

Question Authors:

Terrill Julien MD, John Badylak MD, Ben Taylor MD,

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TAG

(OBQ08.254) Replantation is indicated for which of the following amputations. Topic

Review Topic

1. multiple level amputation of the small finger at the proximal and distal interphalangeal joints
2. crushed amputation through the distal phalanx of the middle finger
3. complete ring avulsion of the ring finger with tendon injury
4. thumb amputation though the proximal phalanx shaft
5. middle finger amputation though the proximal phalanx shaft

PREFERRED RESPONSE ▶

DISCUSSION: As outlined by Pederson, the contraindications to replantation are more relative than the indications, but they include the following: Single-finger replantations at the level of zone II (from the A1 pulley to the distal sublimis tendon insertion) are rarely indicated, with the notable exception of the thumb. Amputated parts that are severely crushed and those with multiple level injuries have poor function even if they survive replantation. While ring avulsion injuries with a vascular injury and no bone, tendon or nerve injury (Urbaniak type 2A ring avulsion injuries) should be repaired, ring avulsion injuries with bone, tendon or nerve injury (Urbaniak type 2B) or with complete degloving (Urbaniak type 3) have poor outcomes and Urbaniak and colleagues recommend amputation for such injuries. Very distal amputations at the level of the nail bed are marginally indicated as there needs to be approximately 4 mm of intact skin proximal to the nailfold for adequate veins to be present. Indications for replantation that rule out the other 4 choices of this question include the following: Overall, thumb replantation probably offers the best functional return. Even with poor motion and sensation, the thumb is useful to the patient as a post for opposition. A replanted thumb offers the best reconstruction available, toe transfers notwithstanding. Replantation beyond the level of the sublimis tendon insertion (zone I) usually results in good function. Multiple finger amputations present reconstructive difficulties that may be difficult to correct without replantation of one or all of the amputated digits. Any hand amputation from zone III (distally) to zone V (proximally) offers the chance of reasonable function after replantation, usually superior to available prostheses. Although usually indicated, the replantation of any hand or arm proximal to the level of the mid-forearm must be carefully considered.

REFERENCES:

1. Pederson WC. Replantation. Plast Reconstr Surg. 2001 Mar;107(3):823-41 PMID:11304612 (Link to Abstract)

2. Trumble et al. Hand Surgery Update 3: Hand, Elbow and Shoulder. ASSH, 2003. 469-47

Question Authors:

Greg Galano MD, Derek Moore, Ben Taylor MD,

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TAG

(OBQ07.257) Each of the following are indications for microvascular replantation EXCEPT? Topic

Review Topic

1. Thumb amputation
2. Index finger amputation in a child
3. Through wrist amputation
4. Long finger amputation through the proximal phalanx
5. Mid-palm amputation of all four fingers

PREFERRED RESPONSE ▶

DISCUSSION: As reviewed by Soucacos, there are several major indications for single digit replantation: 1) Level of the amputation is distal to the insertion of FDS. 2) Amputations at the level of the distal phalanx. 3) Ring avulsion injuries involving both the dorsal and palmar skin and blood supply in an isolated finger, as long as FDS is intact. 4) Any amputation in a child. 5) Thumb amputation. Replantation of a single digit, which is amputated at the level of the proximal phalanx or at the PIP joint, particularly in avulsion or crush injury is contra-indicated. Soucacos also discusses appropriate surgical teams, transport, and other related issues surrounding a "transplant team."

REFERENCES:

1. Soucacos PN. Indications and selection for digital amputation and replantation. J Hand Surg Br. 2001 Dec;26(6):572-81. Review. PMID:11884116 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD, Michael Hughes MD,

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TAG

(OBQ06.45) What is the most important factor influencing immediate and late outcome of digit replantation? Topic

Review Topic

1. Gender
2. Anastamosing the proximal profundus tendon stump to the superficialis tendon of the amputated digit
3. Regular cigarette smoking
4. Utilization of composite skin and subcutaneous vein graft
5. Mechanism of digit amputation injury

PREFERRED RESPONSE ▶

DISCUSSION: The Level 2 study by Waikakul et al is a cohort of 552 patients that underwent 1018 digit replantation. Mechanism of injury was the most important factor influencing the survival rate with an odds ratio of 46.3. Specifically, avulsion, degloving and extensive crushed amputation resulted in a low survival rate and poor functional outcome. Cigarette smoking and male gender were associated with worse results but not to the degree of the mechanism of injury. Utilization of composite skin and subcutaneous vein grafts as well as connecting the profundus to the superficialis at the anastomoses correlated to better outcomes. After the operation, 329 of 946 survived digits (34.7%) in 180 patients (35.4%) needed further reconstructive surgery to improve their function. Tenolysis was the most common procedure followed by staged tendon grafting and capsulotomy.

The review article by Wang found that tendon procedures, specifically tenolysis, accounted for 47.2% secondary surgeries following digit replantation.

REFERENCES:

1. Waikakul S, Sakkarnkosol S, Vanadurongwan V, Un-nanuntana A. Results of 1018 digital replantations in 552 patients. Injury. 2000 Jan;31(1):33-40. PMID:10716048 (Link to Abstract)

2. Wang H. Secondary surgery after digit replantation: its incidence and sequence. Microsurgery. 2002;22(2):57-61. PMID:11921072 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD, Dave Marcu MD,

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TAG

(OBQ06.71) Ischemia induced by the conversion of hypoxanthine to xanthine is thought to be involved in the mechanism of reperfusion injury following restoration of circulation after replantation. Which of the following agents inhibits conversion to xanthine and has been shown to improve outcomes following digit replantation? Topic

Review Topic

1. Tissue plasminogen activator
2. Heparin
3. COX 2 inhibitor
4. Allopurinol
5. Leeches

PREFERRED RESPONSE ▶

DISCUSSION: Allopurinol is a xanthine oxidase inhibitor and may have a beneficial role in replantation. Inhibition of xanthine oxidase also decreases uric acid in patients with gout.

Waikakul et al. published a randomized control trial with a 2-year follow-up comparing thumb replantation with and without adjunctive allopurinol. There were 60 patients in the trial group, and 38 patients in the control group. All were young, healthy laborers who had sharp or locally crushed amputations of the thumb at the proximal phalanx with a total ischemic time >10 hours. The standard management for thumb replantation was used in these patients, except that 300mg allopurinol was given orally in the trial group on admission and a further 300mg for another 5 days. After the operation, the trial group had a lower infection rate, and less postoperative pain and chronic swelling than the control group. Recovery of sensation was also better in the trial group.

REFERENCES:

1. Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 469-477.

2. Waikakul S, Unnanantana A, Vanadurongwan V: The role of allopurinol in digital replantation. J Hand Surg Br 1999;24:325-327. PMID:10433447 (Link to Abstract)

Question Authors:

Sam Cho MD, Patrick McCulloch MD, Michael Hughes MD,

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TAG

(OBQ06.265) Which of the following digit amputations may be considered a relative contraindication for a replantation? Topic

Review Topic

1. Ring finger through the proximal phalanx shaft
2. Mid forearm
3. Thumb through the proximal phalanx
4. Middle, ring, and small fingers through the middle phalanx shaft
5. Complete hand just proximal to the distal palmar crease

PREFERRED RESPONSE ▶

DISCUSSION: Replantation of a single finger amputated proximal to the insertion of the flexor superficialis tendon is a relative contraindication because of the severe stiffness and poor function encountered after repairs in this location.

The FDS insertion is in the middle of the middle phalanx and is also what defines the distal border of Zone II in flexor tendon injuries. If the finger is cut proximal to the insertion of FDS, that means that FDS is also cut and needs to be repaired leading to severe stiffness and worse PIP function. The exceptions are when there are multiple digits injured or in young children.

Urbaniak et al found replantation of a single finger amputated distal to the insertion of the flexor superficialis tendon is justified, but that replantation of a single finger that was amputated proximal to this insertion is not indicated.

Tamai et al found that an amputation of the hand, forearm, arm, and thumb, as well as multiple digits are all criteria for replantation.

REFERENCES:

1. Tamai S. Twenty years' experience of limb replantation--review of 293 upper extremity replants. J Hand Surg Am. 1982 Nov;7(6):549-56. PMID:7175124 (Link to Abstract)

2. Urbaniak JR, Roth JH, Nunley JA, Goldner RD, Koman LA. The results of replantation after amputation of a single finger. J Bone Joint Surg Am. 1985 Apr;67(4):611-9. PMID:3980507 (Link to Abstract)

Question Authors:

Mark Vitale MD, Michael Hughes MD, John Badylak MD,

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TAG

(OBQ05.193) All of the following factors are favorable for digit survival after replantation surgery EXCEPT? Topic

Review Topic

1. Sharply amputated digit
2. Crushed amputated digit
3. Warm ischemia time of 8 hours
4. Patient age of 10 years
5. Female gender

PREFERRED RESPONSE ▶

DISCUSSION: Waikakul et al. in a study of 1018 replantations found that type of injury was the most important factor influencing immediate and late outcome. Extensively crushed injuries had the worst outcome, followed by degloving and avulsion injuries. Sharp cut injuries fared the best. Regular cigarette smoking resulted in poor immediate survival rate and prolonged ischemia had a significant influence in final functional outcome, but neither were as important as mechanism of injury. Alcohol consumption was also a negative predictor. Favorable factors for replantation survival were female gender, age under 13 years old, and nonsmokers. Regarding ischemia time, Miller recommends <12 hours of warm ischemia or <24 hours of cold ischemia for a digit to obtain optimal outcomes.

REFERENCES:

1. Waikakul S, Sakkarnkosol S, Vanadurongwan V, Un-nanuntana A. Results of 1018 digital replantations in 552 patients. Injury. 2000 Jan;31(1):33-40. PMID:10716048 (Link to Abstract)

2. Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 469-477

Question Authors:

Doug Nowak MD, Derek Moore, Patrick McCulloch MD,

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TAG

(OBQ05.239) A 34-year-old male undergoes a thumb replantation after an industrial meat slicer accident. At 4 hours postoperatively there is a drop from 33 degrees celsius to 29 degrees celsius and the pulse oximetry monitor on the thumb reads 87%. All of the following are treatment options for the management of his arterial inflow insufficiency EXCEPT: Topic

Review Topic

1. Administer IV heparin
2. Administer a stellate ganglion block
3. Placement of leeches on the thumb
4. Inspect the dressing for any constriction
5. Place the thumb in a dependent position.

PREFERRED RESPONSE ▶

DISCUSSION: Arterial thrombosis after digit replantation typically occurs within the first 12 hours postoperatively whereas venous thrombosis/congestion occurs after the first 12 hours postoperatively. Leeches excrete Hirudin, which is 100 times more potent than heparin, but are typically used for the treatment of venous thrombosis/congestion and not arterial thrombosis. Miller's review states a drop in temperature >2 C in 1 hour or temperature below 30 C indicates decreased digital perfusion. If arterial insufficiency develops: release constrictive bandages, place the extremity in a dependent position, consider heparinization, consider stellate ganglion blockade, or explore early if these maneuvers do not work.

REFERENCES:

1. Green DP, Hotchkiss RN, Pederson WC. Green's Operative Hand Surgery. Fourth Edition. Philadelphia PA. Churchill Livingston. 1999

Question Authors:

Michael Hughes MD,

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TAG

(OBQ05.270) A 34-year-old male sustains amputations of the 4th and 5th fingers at the level of the middle phalanx after cutting them with a butcher knife. Which of the following techniques would most likely increase total surgical time during replantation? Topic

Review Topic

1. Utilizing an on-call surgical team experienced at digit replantations
2. Digit-by-digit repair method
3. Structure-by-structure repair method
4. Bone shortening procedures to avoid the need for vein grafts
5. Obtaining a thorough inventory of the digit structures that are deficient and the structures that are available for reconstruction

PREFERRED RESPONSE ▶

DISCUSSION: Surgical time in multiple digit replantation is increased by digit-by-digit repair techniques and decreased by structure-by-structure repair techniques.

The Level 5 article by Morrison and McCombe reviews the indications and results of finger replantation. Results of replantation from the DIP to PIP joint typically have good outcomes whereas replantations at the proximal interphalangeal (PIP) joint to MCP joint have poor outcomes due to flexion contractures. The review article by Wang cites that tenolysis and tendon procedures were needed in 47.2% of the published cases of digit replantation and is the leading type of secondary operation.

The classic article by Waikakul et al reviewed 1018 digital replantations in 552 patients. They had a 92% rate of successful outcome and found that type of injury was the most important factor influencing immediate and late outcome.

REFERENCES:

1. Waikakul S, Sakkarnkosol S, Vanadurongwan V, Un-nanuntana A. Results of 1018 digital replantations in 552 patients. Injury. 2000 Jan;31(1):33-40. PMID:10716048 (Link to Abstract)

2. Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA. Churchill Livingstone, 1999, pp 1094-1138

3. Wang H. Secondary surgery after digit replantation: its incidence and sequence. Microsurgery. 2002;22(2):57-61. PMID:11921072 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD, John Badylak MD,

Please Rate Educational Value!

3.0

Average 3.0 of 14 Ratings

Groups

ABOS II: Replantation

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 2 (Prospective Cohort Study)

Waikakul S, Sakkarnkosol S, Vanadurongwan V, Un-nanuntana A. Results of 1018 digital replantations in 552 patients. Injury. 2000 Jan;31(1):33-40. PMID:10716048 (Link to Abstract)

Level of Evidence 4 (Case Series)

Waikakul S, Sakkarnkosol S, Vanadurongwan V, Un-nanuntana A. Results of 1018 digital replantations in 552 patients. Injury. 2000 Jan;31(1):33-40. PubMed PMID: 10716048. PMID:10716048 (Link to Abstract)
Soucacos PN, Beris AE, Malizos KN, Vlastou C, Soucacos PK, Georgoulis AD. Transpositional microsurgery in multiple digital amputations. Microsurgery. 1994;15(7):469-73. PMID:7968476 (Link to Abstract)
Schwabegger AH, Harpf C, Rumer A, Hussl H, Anderl H, Ninkovic MM. Transpositional replantation of digits. Case reports. Scand J Plast Reconstr Surg Hand Surg. 1999 Jun;33(2):243-9. PMID:10450584 (Link to Abstract)
Tamai S. Twenty years' experience of limb replantation--review of 293 upper extremity replants. J Hand Surg Am. 1982 Nov;7(6):549-56. PMID:7175124 (Link to Abstract)
Urbaniak JR, Roth JH, Nunley JA, Goldner RD, Koman LA. The results of replantation after amputation of a single finger. J Bone Joint Surg Am. 1985 Apr;67(4):611-9. PMID:3980507 (Link to Abstract)
Waikakul S, Sakkarnkosol S, Vanadurongwan V, Un-nanuntana A. Results of 1018 digital replantations in 552 patients. Injury. 2000 Jan;31(1):33-40. PMID:10716048 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Boulas HJ. Amputations of the fingers and hand: indications for replantation. J Am Acad Orthop Surg. 1998 Mar-Apr;6(2):100-5. PMID:9682072 (Link to Abstract)
Soucacos PN. Indications and selection for digital amputation and replantation. J Hand Surg Br. 2001 Dec;26(6):572-81. Review. PMID:11884116 (Link to Abstract)
Wang H. Secondary surgery after digit replantation: its incidence and sequence. Microsurgery. 2002;22(2):57-61. PMID:11921072 (Link to Abstract)
Wang H. Secondary surgery after digit replantation: its incidence and sequence. Microsurgery. 2002;22(2):57-61. PMID:11921072 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Green DP, Hotchkiss RN, Pederson WC. Green's Operative Hand Surgery. Fourth Edition. Philadelphia PA. Churchill Livingston. 1999
Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA. Churchill Livingstone, 1999, pp 1094-1138

Undefined

Pederson WC. Replantation. Plast Reconstr Surg. 2001 Mar;107(3):823-41 PMID:11304612 (Link to Abstract)
Trumble et al. Hand Surgery Update 3: Hand, Elbow and Shoulder. ASSH, 2003. 469-47
Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 469-477.
Waikakul S, Unnanantana A, Vanadurongwan V: The role of allopurinol in digital replantation. J Hand Surg Br 1999;24:325-327. PMID:10433447 (Link to Abstract)
Waikakul S, Sakkarnkosol S, Vanadurongwan V, Un-nanuntana A. Results of 1018 digital replantations in 552 patients. Injury. 2000 Jan;31(1):33-40. PMID:10716048 (Link to Abstract)
Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 469-477

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