Updated: 6/22/2017

Replantation

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Questions
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Evidence
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Introduction
  • Trauma is the most common etiology for upper extremity replantation
  • Epidemiology
    • incidence
      • 90% of upper extremity amputation occurred after trauma
    • demographics
      • 4:1 male-to-female ratio
    • location
      • most amputations occur at the level of the digits
  • Pathophysiology
    • mechanism of traumatic amputation
      • sharp dissection
      • blunt dissection
      • avulsion
      • crush
Presentation
  • History
    • timing of injury
    • type and location of amputation
      • number of digits involved
    • preservation of amputated tissue
    • associated injury
    • past medical history
  •  Examination
    • stump examined for 
      • zone of injury 
      • tissue viability
      • supporting tissue structures
      • contamination
    • amputated portion inspected
      • segmental injury
      • bone and soft tissue envelope
      • contamination  
Indications 
  • Indications for replantation after trauma
    • primary indications
      • thumb at any level  
      • multiple digits 
      • through the palm
      • wrist level or proximal to wrist  
      • almost all parts in children
    • relative indications
      • individual digits distal to the insertion of flexor digitorum superficialis [FDS] (Zone I) 
      • ring avulsion
      • through or above elbow
  • Contraindications to replantation
    • primary contraindications
      • severe vascular disorder
      • mangled limb or crush injury 
      • segmental amputation 
      • prolonged ischemia time with large muscle content (>6 hours)
    • relative contraindications
      • single digit proximal to FDS insertion (Zone II)  
      • medically unstable patient
      • disabling psychiatric illness
      • tissue contamination
      • prolonged ischemia time with no muscle content (>12 hours)
Treatment
  • Transport of amputated tissue
    • indications
      • any salvageable tissue should be transported with the patient to hospital
    • modality
      • keep amputated tissue wrapped in moist gauze in lactate ringers solution
      • place in sealed plastic bag and place in ice water (avoid direct ice or dry ice)
      • wrap, cover and compress stump with moistened gauze
  • Operative
    • 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
    • general operative sequence of replantation  
      1. vascular shunt first (for proximal replantation with large muscle mass to minimize warm ischemia time)
      2. bone fixation +/- shortening (after irrigation and debridement of soft-tissue and bone)
      3. extensor tendon repair
      4. artery repair(repair second after bone if ischemic time is >3-4 hours)
      5. venous anastomoses
      6. flexor tendon repair
      7. nerve repair
      8. skin +/- fasciotomy
    • 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 temperature most reliable
      • concerning changes include a > 2° drop in skin temp in less than one hour or a temperature below 30° celsius
    • pulse oximetry
      • < 94% indicates potential vascular compromise
  • Anticoagulation
    • adequate hydration
    • medications (aspirin, dipyridamile, low-molecular weight dextram, heparin)
  • Arterial Insufficiency 
    • treat with
      • release constricting 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 application
        • releases Hirudin (powerful anticoagulant)
        • Aeromonos hydrophila infection can occur (prophylax with Bactrim or ciprofloxacin)
      • heparin soaked pledgets if leeches not available
Complications
  • Replantation failure
    • most frequently cause within 12 hours is arterial thrombosis from persistent vasospasm
  • Stiffness
    • replanted digits have 50% of total motion
    • tenolysis is most common secondary surgery 
  • Myonecrosis
    • greater concern in major limb replantation than in digit replantation
  • 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 
  • Infection
  • Cold intolerance
 

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Questions (13)
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(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: Review Topic

QID: 1125
1

Administer IV heparin

3%

(54/2096)

2

Administer a stellate ganglion block

14%

(292/2096)

3

Placement of leeches on the thumb

64%

(1349/2096)

4

Inspect the dressing for any constriction

1%

(14/2096)

5

Place the thumb in a dependent position.

18%

(369/2096)

ML 3

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PREFERRED RESPONSE 3

(OBQ12.135) A 42-year-old male sustains the injury seen in Figure A. Which of the following is true regarding management of this injury? Review Topic

QID: 4495
FIGURES:
1

Replantation at this level has a worse functional outcome when compared to above the elbow amputations

8%

(291/3704)

2

The veins should be reconstructed prior to the arteries

15%

(570/3704)

3

Bony stabilization should occur at the end of the procedure

3%

(99/3704)

4

Vein grafting should not be used at this level of amputation

3%

(102/3704)

5

A warm ischemia time of 8 hours is a relative contraindication to replantation

70%

(2601/3704)

ML 3

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PREFERRED RESPONSE 5

(OBQ12.15) A 30-year-old healthy female sustains a traumatic digit amputation while working at a factory. Which of the following is a absolute indication for digit replantation in this patient? Review Topic

QID: 4375
1

Isolated amputation of the index finger proximal to the FDS insertion

6%

(266/4370)

2

Amputation due to crush injury

1%

(57/4370)

3

Replantation of an index finger with a segmental injury

2%

(76/4370)

4

Isolated amputation of the thumb proximal to the FPL insertion

89%

(3875/4370)

5

Presentation 13 hours after the amputation occurred

1%

(60/4370)

ML 2

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PREFERRED RESPONSE 4

(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? Review Topic

QID: 182
1

Tissue plasminogen activator

3%

(26/977)

2

Heparin

5%

(50/977)

3

COX 2 inhibitor

6%

(56/977)

4

Allopurinol

79%

(775/977)

5

Leeches

6%

(57/977)

ML 2

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PREFERRED RESPONSE 4

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

QID: 276
1

Ring finger through the proximal phalanx shaft

79%

(2197/2765)

2

Mid forearm

5%

(141/2765)

3

Thumb through the proximal phalanx

1%

(31/2765)

4

Middle, ring, and small fingers through the middle phalanx shaft

9%

(260/2765)

5

Complete hand just proximal to the distal palmar crease

4%

(120/2765)

ML 1

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PREFERRED RESPONSE 1

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

QID: 156
1

Gender

0%

(5/1345)

2

Anastamosing the proximal profundus tendon stump to the superficialis tendon of the amputated digit

1%

(15/1345)

3

Regular cigarette smoking

20%

(268/1345)

4

Utilization of composite skin and subcutaneous vein graft

1%

(13/1345)

5

Mechanism of digit amputation injury

77%

(1030/1345)

ML 2

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PREFERRED RESPONSE 5

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

QID: 918
1

Thumb amputation

0%

(8/1896)

2

Index finger amputation in a child

3%

(49/1896)

3

Through wrist amputation

4%

(78/1896)

4

Long finger amputation through the proximal phalanx

86%

(1631/1896)

5

Mid-palm amputation of all four fingers

6%

(113/1896)

ML 1

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PREFERRED RESPONSE 4

(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? Review Topic

QID: 3589
FIGURES:
1

Transpositional microsurgery offers the best results

7%

(211/2910)

2

Replantation is contraindicated as the injury is through flexor zone II

2%

(68/2910)

3

Replantation is contraindicated because of the extent of injury

5%

(158/2910)

4

Heterotopic transplantation would offer the best function

2%

(62/2910)

5

Anatomic replantation of hand offers the best results

82%

(2396/2910)

ML 2

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PREFERRED RESPONSE 5

(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? Review Topic

QID: 1156
1

Utilizing an on-call surgical team experienced at digit replantations

1%

(13/2143)

2

Digit-by-digit repair method

77%

(1647/2143)

3

Structure-by-structure repair method

14%

(309/2143)

4

Bone shortening procedures to avoid the need for vein grafts

1%

(32/2143)

5

Obtaining a thorough inventory of the digit structures that are deficient and the structures that are available for reconstruction

6%

(129/2143)

ML 2

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PREFERRED RESPONSE 2

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

QID: 640
1

multiple level amputation of the small finger at the proximal and distal interphalangeal joints

0%

(11/2374)

2

crushed amputation through the distal phalanx of the middle finger

0%

(6/2374)

3

complete ring avulsion of the ring finger with tendon injury

1%

(20/2374)

4

thumb amputation though the proximal phalanx shaft

97%

(2294/2374)

5

middle finger amputation though the proximal phalanx shaft

1%

(35/2374)

ML 1

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PREFERRED RESPONSE 4

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

QID: 1079
1

Sharply amputated digit

1%

(16/3020)

2

Crushed amputated digit

97%

(2919/3020)

3

Warm ischemia time of 8 hours

2%

(67/3020)

4

Patient age of 10 years

0%

(5/3020)

5

Female gender

0%

(5/3020)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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